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Physical Dx > L6: Pulmonary & Chest Assessment > Flashcards

L6: Pulmonary & Chest Assessment Flashcards

1
Q

Chest Anatomical Terms

  • Supraclavicular
  • Infraclavicular
  • Interscapular
  • Infrascapular
  • Upper, middle and lower lung fields
  • Apex of the lungs
  • Bases of the lungs
A
  • Supraclavicular: above clavicle
  • Infraclavicular: below clavicle
  • Interscapular: between scapulae
  • Infrascapular: below scapulae
  • Upper, middle and lower lung fields
  • Apex of the lungs: most superior portion of the lungs
  • Bases of the lungs:lowest portion of lungs
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2
Q

Vertical Axis Landmarks (anterior)

Angle of Louis

2nd Rib

A
  • Sternal angle (aka Angle of Louis)
    • Bony ridge that joins the manubrium and sternal body
      • Located approximately 5cm below the suprasternal notch
  • 2nd rib
    • located lateral to sternal angle
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3
Q

Counting Ribs (anterior)

Counting ribs: how?

Intercostal spaces: define

A
  • Counting ribs
    • Walk fingers laterally from sternal angle to the 2nd rib
    • Continue walking fingers down, at an angle, to count ribs and intercostal spaces
  • Intercostal spaces
    • Space between two ribs, numbered by rib above:
      • 2nd left intercostal space (2nd LICS) is below the 2nd rib
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4
Q

Vertical axis landmarks (posterior)

12th rib

Inferior tip of scapula

Spinous process of C7

A
  • 12th rib
    • Start here and walk up the interspaces to count ribs/interspace
  • Inferior tip of scapula
    • Correlates with 7th rib/intercostal space
  • Spinous process of C7
    • Count down from C7: T1 = first rib
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5
Q

Circumferential Landmarks

What are the anterior landmarks?

What are the axillary landmarks?

A
  • Anterior circumferential landmarks
    • Midsternal line (MSL) - precise
    • Midclavicular line (MCL) - estimated
    • Anterior axillary line (AAL) - estimated
  • Axillary circumferential landmarks
    • Posterior axillary line (PAL)
      • Drops from posterior axillary fold
    • Midaxillary line (MAL)
      • Drops from apex of axilla
    • Anterior axillary line (AAL)
      • Drops from anterior axillary fold
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6
Q

Lung basics

R & L long lobes

Lung apices: location

Lower lung borders

A
  • Right lung
    • 3 lobes: RUL, RML, RLL
  • Left lung
    • 2 lobes: LUL, LLL
  • Lung apices
    • ~2-4cm above clavicle
  • Lower lung borders
    • 6th rib midclavicular line
    • 8th rib midaxillary line
    • T10 posteriorly
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7
Q

Lung basics

Major & minor fissures

What are the other names for these fisures?

Location?

A
  • Major (Oblique) fissure
    • Divides each lung in half
    • From T3 spinous process obliquely around chest to 6th rib at midclavicular line
  • Minor (Horizontal) fissure
    • R lung only
    • Runs close to 4th rib, meeting major fissure at midaxillary line near 5th rib
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8
Q

Trachea & Major Bronchi

Trachea: location

Bronchi: where does it bifurcate

A
  • Trachea
    • Normal position: midline
    • Bifurcates into R & L mainstem bronchi at the level of the sternal angle (anteriorly) and T4 (posteriorly)
  • NOTE: breath sounds over trachea and bronchi are different than breath sounds over lung parenchyma.
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9
Q

Respiration

What is the normal respiration rate?

Sounds?

What occurs during inspiration and expiration?

A
  • Normal rate: 12-20 breaths/min
  • Quiet, slight thorax movement, more prominent abdominal movement
  • Inspiration – diaphragm contracts, chest wall expands, negative intrathoracic pressure draws air into lungs
  • Expiration – diaphragm relaxes, chest wall contracts, intrathoracic pressure normalizes, air leaves lungs
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10
Q

Neck Abnormalities

What are the common neck abnormalities?

A
  • Stridor
  • Tracheal deviation
  • Accessory muscle use
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11
Q

Stridor

What does it sound like?

What does it indicate?

Cause?

What can it lead to in kids?

A
  • High-pitched usually inspiratory wheeze
  • Indicates obstruction in trachea or larynx
  • Foreign body or airway disease
  • Croup in kiddos
  • Displacement of the trachea from midline
  • Causes: Large pleural effusion, large pneumothorax, mass/tumor
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12
Q

Tracheal Deviation

What is tracheal deviation?

Causes?

A
  • Displacement of the trachea from midline
  • Causes:
    • Large pleural effusion
    • Large pneumothorax
    • Mass/tumor
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13
Q

Accessory Muscle Use

What is this a sign of?

What to look for?

What illnesses is it comonly seen in?

A
  • Sign of respiratory distress
  • Look for sternocleidomastoid, scalene, supraclavicular contraction
  • Seen with COPD, asthma…
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14
Q

Thorax Abnormalities

Pectus excavatum

A

Pectus Excavatum (Funnel Chest)

Concave anterior chest

Depression of distal sternum

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15
Q

Thorax Abnormalities

Pectus Carinatum

A

Pectus Carinatum (Pigeon Chest)

  • Convex anterior chest
  • Anterior displacement of sternum
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16
Q

Thorax Abnormalities

Barrel chest

A

Barrel Chest: Increased A-P (anteroposterior) diameter

  • Seen in aging, COPD
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17
Q

Thorax Abnormalities

Flail Chest

A

Flail Chest: rib fractures cause paradoxical movement of chest wall

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18
Q

Thorax Abnormalities

Kyphosis

A

Kyphosis: abnormal forward curvature of spine

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19
Q

Thorax Abnormalities

Scoliosis

A

Scoliosis: abnormal lateral curvature of the spine

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20
Q

Bradypnea vs. Tachypnea

Fast/slow?

Breaths/min?

Commonly seen in what medical conditions?

A
  • Normal:
    • 14-20 breaths/min
  • Bradypnea: slow
    • <12 breaths/min
    • Diabetic coma, drug-induced respiratory depression
  • Tachypnea: rapid, shallow depth
    • >20 breaths/min
    • Restrictive lung disease, elevated diaphragm, pain
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21
Q

Hyperventilation vs. sighing

What are they commonly seen in?

A
  • Hyperventilation: faster, deeper respiration
    • Metabolic acidosis (Kussmaul breathing)
  • Sighing: periodic deeper breaths
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22
Q

Obstructive Breathing

What is it?

What conditions is it commonly seen in?

A
  • Prolonged expiration and increased airway resistance
  • Asthma, chronic bronchitis, COPD
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23
Q

Kussmaul Breathing

What is it?

What is it a sign of?

A

Rapid & deep respiration

Sign of metabolic acidosis

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24
Q

Cheyne-Stokes Breathing

What is it?

Causes?

A
  • Periods of gradually increasing and decreasing depth of respirations with periods of apnea (no breathing)
  • Can be normal in sleeping children, elderly
  • Causes include
    • Heart failure
    • Uremia
    • Brain damage
    • Drug-induced
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25
Q

Biot’s Breathing

What is it?

Cause?

A

Irregular, unpredictable, shallow or deep, with intermittent apnea

Respiratory depression, brain damage

26
Q

Apnea

What is it?

A

The absence of spontaneous respiration

27
Q

Crepitus

What condition is it usually seen in?

A

Palpation Abnormality

  • Crepitus: crackling/grating feeling or sound
  • Rib movement from fracture (bone crepitus)
  • Subcutaneous emphysema (subQ crepitus) – feels like “Rice Krispies” under the skin
28
Q

Limited chest excursion

A

Palpation Abnormalities

Limited chest excursion: Unilaterally from chronic lung/pleural fibrosis, pleural effusion, lobar pneumonia, pain/splinting

29
Q

Subcutaneous Emphysema

What is it?

What can it cuse?

What is it seen in?

A

Air from lung/chest tracks along tissue planes

Can cause: “swelling” of eyelids, cheeks, lips, neck, chest

Seen w/lung injury (rib fx), postop thoracic surgery, etc.

30
Q

Fremitus

Define

A

Fremitus: Palpable vibrations transmitted through bronchiopulmonary tree to chest wall with patient verbalization

31
Q

Abnormal Tactile Fremitus

What are the cause(s) of:

Decreased fremitus

Increased fremitus

A
  • Decreased fremitus (vibration)
    • Obstructed bronchus
    • COPD
    • Pleural effusion
    • Lung fibrosis
    • Pneumothorax
  • Increased fremitus (vibration)
    • Pneumonia/consolidation
32
Q

Percussion

Purpose

Technique

A
  • Purpose:
    • Determine if underlying tissues are air-filled, fluid-filled, or solid (up to 7cm deep into chest)
    • Detect areas of tenderness (spine, ribs, etc) Technique:
  • Technique:
    • Finger of one hand strikes the finger of the other hand, not striking the patient directly
    • For louder notes, apply more pressure to finger on chest wall
33
Q

What are the locatoins for chest perucssion & ascultation

Anteriorly

Posteriorly

A

Note: Required for Exam - 3 levels anteriorly, 4 levels posteriorly, plus 1 lateral site on each side

34
Q

Chest Percussion Tones

Resonant

Dull

Flat

Tympanic

A

Resonant over air (lungs)

Dull over solid (liver)

Flat over fluid-filled areas/bone/muscle

Tympani over hollow areas (stomach)

35
Q

Normal Percussion Tones

A
36
Q

Abnormal percussion tones

What conditions might be associated with the following tones?

Hyper-resonant

Resonant

Tympanic

Dull

Flat

A
  • Hyper-resonant
    • COPD
    • Pneumothorax (PTX)
  • Resonant
    • Chronic bronchitis
  • Tympanic
    • Large pneumothorax
  • Dull
    • Pneumonia
    • Pleural effusion
  • Flat
    • Pleural effusion
37
Q

Characteristics of Breath Sounds

A
38
Q

Adventitious Sounds

What are adventitious sounds?

Crackles

Rhonchi

Wheezes

A
  • Adventitious Sounds: Sounds are superimposed on usual breath sounds
    • “Adventitious” = added
  • Crackles: discontinuous sounds
  • Rhonchi: continuous, low-pitched
  • Wheezes: continuous, high-pitched
39
Q

Crackles

Continuous or discontinuous?

Sound?

Conditions where these sounds may be present

Fine vs. coarse crackles: sound/pitch/duration?

A
  • Adventitious Sounds: Discontinuous
  • Intermittent, nonmusical, brief, velcro-like sounds
  • Heard when small airways pop open during inspiration or when air bubbles flow through secretions or closed airways
  • Bronchitis, pulmonary fibrosis, CHF
  • Fine crackles: soft, high pitched, very brief (5-10msec)
  • Coarse crackles: louder, lower pitch, brief (20-30msec)
40
Q

Rhonchi & Wheezes

Continuous or discontinuous?

What are they?

Duration?

Pitch?

Seen in what conditions?

A
  • Adventitious Sounds: Continuous
  • Longer (≥250 msec), musical
  • Rhonchi – suggest secretions in larger airways, often clear with cough
    • Low pitched, snoring “wheeze”
    • Large airway secretions (chronic bronchitis)
  • Wheeze – rapid airflow through narrowed (almost closed) bronchi
    • High-pitched, hissing, shrill, whistling
    • Asthma, COPD, chronic bronchitis, bronchus obstruction,
    • Stridor – inspiratory wheeze (larynx/tracheal obstruction)
41
Q

Pleural friction rub

What is it?

Cause?

A

Adventitious Sound

  • Pleural Friction Rub – crackle-like creaking sounds
  • Inflamed pleural surfaces rubbing together
  • Recent URI, pneumonia, etc.
42
Q

Mediastinal crunch

What is it also called?

What is it?

Cause?

Where/how is it best heard?

A
  • Mediastinal Crunch aka “Hamman’s Sign”– precordial crackles in sync with heartbeat, not respiration
  • Mediastinal emphysema (pneumomediastinum)
  • Best heard in left lateral position
43
Q

Specialized Exam

Respiratory Expansion

How to test?

A

How to test

  1. Place your thumbs at the level of the 10th ribs, your fingers parallel to lateral rib cage
  2. Slide your hands medially to loosen skin folds
  3. Ask the patient to inhale deeply
  4. Make note of how your thumbs diverge as the thorax expands – distance and symmetry
44
Q

Specialized Exam

Tactile Fremitus

How to test?

Normal/abnormal

A

How to test: Place ulnar side of hand against chest wall and ask patient to say “99”, feeling for vibrations

Normal: Palpable vibrations

Abnormal: increased or decreased vibrations

45
Q

Specialized Exam

Diaphragmatic Excursion

What is it?

How to test?

Normal?

A
  • What is it: the movement of the thoracic diaphragm during breathing
    • Measures the contraction of the diaphragm.
  • How to test:
  • Normal: 3 - 5.5 cm
46
Q

Specialized Exam

Bronchophony

What is it?

Purpose?

How to test?

Normal/abnormal?

A
  • What is it:
    • abnormal transmission of sounds from the lungs or bronchi
    • Transmitted voice sound
    • Presence indicates lung consolidation/collapse
      • e.g. pneumonia, atelectasis, tumors
  • Purpose: Assess underlying lung tissue for collapse/consolidation
  • How to test: Ask patient to say “99” while auscultating lung fields
  • Normal lung: spoken words are muffled & indistinct
  • Abnormal lung: louder voice sounds, called bronchophony
47
Q

Specialized Exam

Egophony

What is it?

Purpose?

How to test?

Normal/abnormal?

A
  • What is it:
    • increased resonance of voice sounds heard when auscultating the lungs
    • Presence indicates lung consolidation/collapse
      • e.g. pneumonia, atelectasis, tumors
  • Purpose: Assess underlying lung tissue for collapse/consolidation
  • How to test: Ask patient to say “EE” while auscultating lung fields
    • When patient says “EE”, it sounds like nasally “AAY” during auscultation
    • “E-A change” present
  • Normal lung: muffled long “EE” sound
  • Abnormal: if “EE” sound changes to “AAY”, Egophony is present
48
Q

Specialized Exam

Whispered Pectoriloquy

Purpose?

How to test?

Normal/abnormal?

A
  • Purpose:
    • Assess underlying lung tissue for collapse/consolidation
  • How to test:
    • Ask patient to whisper “1-2-3” while auscultating lung fields
  • Normal lung:
    • whispered words inaudible/barely audible
  • Abnormal:
    • Louder, clearer whispered sounds are called Whispered Pectoriloquy
49
Q

Pleural Effusion

What is it?

A

Pleural Effusion: fluid collection within the chest but outside the lung, causing lung compression

50
Q

Pneumothorax

What is it?

A

Pneumothorax: air collection within the chest but outside the lung, causing lung compression

51
Q

COPD

What does it stand for?

What is it?

A

COPD (Chronic Obstructive Pulmonary Disease): over-distention of distal airspaces, resulting in limited expiratory flow and lung hyperinflation

52
Q

Consolidation/infiltrate

What is it?

A

Consolidation/infiltrate: alveoli filled with fluid/blood/pus increasing the density and opacity of the lung tissue

53
Q

Normal, Air-Filled Lung

Percussion

Breath sounds

Transmitted voice sounds

Tactile fremitus

A

Percussion: Resonant

Breath sounds: Mostly vesicular except over large bronchi (bronchovesicular) and trachea (bronchial)

Transmitted voice sounds: Normal

Tactile fremitus: Normal

54
Q

Pneumonia (consolidation)

Percussion

Breath sounds

Transmitted voice sounds

Tactile fremitus

A
  • Percussion: Dull over affected area
  • Breath sounds: Bronchial over involved area, crackles
  • Transmitted voice sounds: Increased
    • Bronchophony: Present (spoken words are louder, clearer)
    • Egophony: Present (“EE” to “AAY” change present)
    • Whispered Pectoriloquy: Present (whispers sound loud)
  • Tactile fremitus: Increased
55
Q

Infintrate vs. Effusion

A
56
Q

Pleural Effusion

Percussion

Breath sounds

Transmitted voice sounds

Tactile fremitus

A
  • Percussion: Dull to flat over fluid
  • Breath sounds: Decreased or absent over fluid
    • Possible pleural rub
  • Transmitted voice sounds: Decreased to absent
  • Tactile fremitus: Decreased to absent
57
Q

Pneumothorax

Percussion

Breath sounds

Transmitted voice sounds

Tactile fremitus

A
  • Percussion: Hyperresonant or tympanic over pleural air pocket
  • Breath sounds: Decreased to absent over pleural air pocket
    • possible pleural rub
  • Transmitted voice sounds: Decreased to absent over air pocket
  • Tactile fremitus: Decreased/absent over pleural air pocket
58
Q

COPD

Percussion

Breath sounds

Transmitted voice sounds

Tactile fremitus

Inspection

A
  • COPD = Chronic Obstructive Pulmonary Disease
  • Percussion: Resonant to diffusely hyperresonant
  • •Breath sounds: Obscured by high pitched wheezes, possible crackles
  • Transmitted Voice Sounds: Decreased
  • Tactile fremitus: Decreased
  • Inspection: Possible accessory muscle use
59
Q

Asthma

Percussion

Breath sounds

Transmitted voice sounds

Tactile fremitus

Inspection

A
  • Percussion: Resonant to diffusely hyperresonant
  • Breath sounds: Obscured by high pitched wheezes, possible crackles
  • Transmitted voice sounds: Decreased
  • Tactile fremitus: Decreased
  • Inspection: Possible accessory muscle use
60
Q

Chronic Bronchitis

Percussion

Breath sounds

Transmitted voice sounds

Tactile fremitus

A

Percussion: Resonant (normal)

Breath sounds: Vesicular (normal), possible crackles, wheezes, or rhonchi

Transmitted voice sounds: Normal

Tactile fremitus: Normal

61
Q

What is the breath pattern?

A

Physical Dx (11 decks)

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