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Clinical Medicine > L13: The Thorax and Lungs > Flashcards

L13: The Thorax and Lungs Flashcards

1
Q

Principle muscles of inspiration? Accessory muscles?

A
  1. ) Principle: External intercostals, interchondral part of internal intercostals, diaphragm
  2. ) Accessory: SCM, scalenes
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2
Q

Muscles of expiration used in quiet vs active breathing?

A
  1. ) Quiet: passive recoil of lungs, no muscles

2. ) Active: internal intercostals except interchondral part, abdominal muscles

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3
Q

Why can patients with difficulty breathing have neck and pubic pain?

A
  • Accessory muscles with inspiration = SCM and scalenes

- Active expiration uses abdominal muscles

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4
Q

At what level of the sternum does the trachea bifurcate?

A
  • Sternal angle
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5
Q

To what vertebral level are the lungs seen in a lateral x-ray?

A
  • T10
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6
Q

Clinical borders of the thorax

A
  • Midsternal line
  • Midclavicular line
  • Anterior axillary line
  • Midaxillary line
  • Posterior axillary line
  • Scapular line
  • Vertebral line
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7
Q

What surface landmarks do the oblique and horizonal fissure(s) of the lungs correspond?

A
  1. ) Horizontal (right lung): 4th rib at sternum and 5th rib at midaxillary line
  2. ) Oblique (both): 6th rib at midaxillary line, posteriorly below spinous process of T3
    * both with inhalation
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8
Q

Difference between right and left primary bronchi. Relevance

A
  • Right more vertical/straighter than left, aspirated FB with more often be in right
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9
Q

Where are bronchial breath sounds heard?

A
  • around the angle of Louis, not found deep in chest
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10
Q

Common or concerning symptoms involving thorax and lungs ordered from high to low seriousness

A
  • Chest pain
  • SOB (dyspnea)
  • Wheezing
  • Cough
  • Hemoptysis (blood-streaked sputum)
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11
Q

Sources of chest pain?

A
  1. ) Cardiac: myocardium, pericardium, aorta
  2. ) Pulmonary: trachea, large bronchi, parietal pleura
  3. ) Other: chest wall, esophagus, extra thoracic
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12
Q

Sources of dyspnea/SOB?

A
  1. ) Lung: COPD (chronic bronchitis, emphysema), pneumonia, asthma, acute bronchitis, PE, pneumo
  2. ) Other: chest wall, compression fracture, phrenic nerve, neurogenic (central or peripheral), psychologic (panic attack), systemic (anemia, low volume, heart failure, sepsis), heart attack, epigastric
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13
Q

Sources of wheeze, cough, hemoptysis?

A
  1. ) Lung: cancer, COPD, pneumonia, asthma, acute bronchitis
  2. ) Nose and mouth: allergic rhinitis, aspiration, irritant
  3. ) Stomach: reflux, bulimia, cyclic vomiting syndrome
  4. ) Other: phrenic nerve, neurogenic (central or peripheral), psychological (habit cough or chronic throat clearing), systemic (bleeding problem)
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14
Q

Order of lung/thorax exam

A
  • Look, listen, palpate, percuss
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15
Q

What are you looking for in the “look” part of the lung/thorax exam?

A
  • Shape: barrel chest, pectus carinatum/excavatum, scoliosis, kyphosis
  • Movement: paradoxical movement of chest / flailed chest – requires 3 ribs broken in two different places
  • Posture: tripod posture (seen in COPD and epiglottitis)
  • Acting: ill, agitate, calm
  • Accessory muscle use
  • Other: cyanosis, edema, bad breath, clubbing, needle marks
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16
Q

Bell or diaphragm for lung vs heart?

A
  • Bell / diaphragm for heart

- Diaphragm for lung

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17
Q

What are you palpating for in the “palpate” part of the lung/thorax exam?

A
  • Symmetry of rib motion
  • Pulmonary embolism (can cause localized collapse of lungs, ribs won’t move over these area). Pleural effusion is more global
  • Pneumonia with consolidations (fremitus)
  • AP-diameter (COPD)
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18
Q

From what side of the thorax can the middle lobe be percussed?

A
  • Anterior only
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19
Q

When percussing the thorax, how will pleurisy be detected?

A
  • Painful to percussion
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20
Q

Sound of consolidation when percussed?

A
  • Dull
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21
Q

Note for normal pt’s thorax/lung exam

A
  • Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no rales, wheezes or rhonchi. Diaphragm descends 4 cm bilaterally
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22
Q

Note for COPD pt’s thorax/lung exam

A
  • Thorax symmetric with moderate kyphosis and increased AP diameter, decreased expansion. Lungs are hyperresonant. Breath sound distant with delayed expiratory phase and scattered expiratory wheezes. Fremitus decreased; no bronchophony, egophony, or whisphered pectoriloquy. Diaphragms descend 2 cm bilaterally
23
Q

Note for asthma pt’s thorax/lung exam

A
  • Thorax symmetric with flattened kyphosis and normal AP diameter. Lungs are resonant. Broncho-vesicular breath sounds and scattered expiratory wheezes bilaterally. Wheezes strongly with forced expiration. No bronchopohony, egophony, or whisphered pectoriloquy. Diaphragms descend 4 cm bilaterally.
24
Q

Note for pneumothorax pt’s thorax/lung exam

A
  • Thorax asymmetric with decreased movement on the left. Lung is hyperresonant on the left. Breath sounds decreased on the left in all lobes. Diaphragm descends 4 cm on right, not percussed on left.
25
Q

Retractions

A
  • Chest wall caving in at sternum, between ribs, suprasternal notch, above clavicles and at lower costal margins
26
Q

Stridor

A
  • harsh, high-pitched sound caused by laryngeal or tracheal obstruction
27
Q

Tactile fremitus

A
  • Vibration
  • Increased is suggestive of fluids/secretions or a solid mass
  • Diminished or absent is suggestive of excess air in lungs caused by obstruction, emphysema, significant effusion or collapse of lung tissue
28
Q

Percussion tones heard over chest

A
  1. ) Resonant
  2. ) Flat
  3. ) Dull
  4. ) Tympanic
  5. ) Hyperresonant
29
Q

Percussion of chest. Direct or indirect?

A
  • Indirect
30
Q

How many areas of percussion/auscultation of chest? Where?

A
  • 12 total

- 4 anteriorly, 2 laterally, 6 posteriorly

31
Q

How to test for diaphragmatic excursion?

A
  1. ) Have pt take deep breath and hold it
  2. ) Percuss down back until hearing change from resonant to dull tone
  3. ) Mark this area as lower border
  4. ) Have pt relax, exhale and hold it
  5. ) Percuss up from marked area until change from dull to resonant tone
  6. ) Mark this area and measure
  7. ) Normal = 3-5 cm
32
Q

What conditions limit diaphragmatic excursion?

A
  • Emphysema, massive ascites, tumor and fractured ribs
33
Q

4 adventitious breath sounds

A
  • Crackles
  • Rhonchi
  • Wheezes
  • Friction rubs
34
Q

Crackles

A
  • Formerly rales
  • Disruption of air passage through small airways, sounds do not clear with coughing
  • Usually heard with inspiration, discontinuously
35
Q

Rhonchi

A
  • Airway obstruction by thick secretions, muscular spasm or external pressure
  • Usually heard with expiration continuously, may clear with coughing
36
Q

Friction rubs

A
  • dry, crackly, grating low-pitched sounds heard in both inspiration and expiration
  • indicates inflammation
37
Q

3 vocal resonance tests

A
  1. ) Bronchophony – having pt say 99
  2. ) Egophony – having pt say ee
  3. ) Whisphered pectoriloquy – having pt whispher 1,2, 3
38
Q

Abnormal breathing patterns

A
  1. ) Cheyne-Stokes: alternating periods of apnea and hyperpnea (increased depth of breathing). Seen in 30% of pts with CHF and also in pts with neuro disorders, hemorrhage, infarction, tumors, meningitis, head trauma. Normal persons can have this during sleep or at high altitudes
  2. ) Kussmaul: very deep, gasing and rapid breathing seen in metabolic acidosis
  3. ) Grunting: short and explosive sounds, more common in children, but also in adults as sign of respiratory muscle fatigue
39
Q

Asthma

A
  • aka reactive airway disease

- small airway obstruction caused by inflammation and hyperactive airways

40
Q

Atelectasis

A
  • incomplete expansion of lung
41
Q

Barrel chest

A
  • increased AP diameter often with some kyphosis, commonly seen in COPD
42
Q

Biot respirations

A
  • irregular respirations varying in depth and interrupted by intervals of apnea that lacks repetitive pattern
43
Q

Bronchiectasis

A
  • chronic dilation of bronchi and bronchioles caused by repeated infections or bronchial obstructions
44
Q

Bronchitis

A
  • inflammation of large airways
45
Q

Bronchophony

A
  • exaggeration of vocal resonance emanating from bronchus surrounded by consolidated lung tissue
46
Q

Bronchiolitis

A
  • inflammation of bronchioles
47
Q

COPD

A
  • disease process which decreases ability of lungs to perform their function of ventilation
  • this is non-specific diagnosis and includes: emphysema and chronic bronchitis
48
Q

Egophony

A
  • auditory quality associated with increased intensity of spoken voice along with nasal quality. May be present in any condition that consolidates lungs
49
Q

3 types of normal breath sounds

A
  1. ) Vesicular: heart over most of the lung fields (low pitch, soft, short expirations)
  2. ) Tubular: heard only over trachea (high pitch, loud and long expirations, sometimes longer than inspiration)
  3. ) Bronchovesicular: heard over main bronchus area and over right upper posterior lung field (medium pitch, expiration = inspiration)
50
Q

Orthopnea

A
  • SOB increasing when pt lies down
51
Q

Pectoriloquy

A
  • striking transmission of voice sounds through the pulmonary structures, so that they are clearly audible through the stethoscope, commonly occurs from lung consolidation
52
Q

Tactile fremitus

A
  • Tremor or vibration in any part of the body detected on palpation
53
Q

Whispered pectoriloquy

A
  • increase in volume of voice sounds when lung is consolidated by pneumonia

Clinical Medicine (11 decks)

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