Lecture 4.1 physical exam section

Question 1

What are the 6 steps of an initial respiratory survey?

Answer 1

1) Listen for audible breathing
2) Assess rate > 25 signals distress
3) Inspect for retractions
4) Inspect the neck for accessory muscle use
5) Observe chest expansion
6) Check AP diameter

Question 2

1) When you’re listening for audible breathing, what is ominous? What can cause this?
2) What should you check if they’re in distress?

Answer 2

1) Inspiratory stridor is ominous for upper airway obstruction: FB, or edematous tissue occluding airway
2) If they are in distress, check for color change (cyanosis and pallor)

Question 3

1) What can cyanosis indicate?
2) When can pallor occur?
3) When does nail clubbing occur? Give examples

Answer 3

1) Cyanosis indicates hypoxia
2) Pallor can occur in heart failure
3) Clubbing of the nails occurs in chronic hypoxia:
COPD, Cancer, Bronchiectasis, congenital heart disease, CF

Question 4

1) What RR signals distress?
2) What else should be assessed while you’re assessing RR?

Answer 4

1) >25/ min
2) Assess regularity of breathing

Question 5

What two things should you observe while you’re observing chest expansion?

Answer 5

1) Bony deformity
2) Unilat impairment of motion

Question 6

What should you be looking for when checking AP diameter?

Answer 6

Pt should be wider than they are deep; if they are nearly equal, it is a sign of advancing COPD

Question 7

1) What can cause tenderness with palpation of the chest?
2) What should be compressed?
3) What should be palpated for tenderness?

Answer 7

1) Inflamed pleura / muscle soreness
2) The chest anterior to posterior
3) Costal cartilage tenderness (costochondritis)

Question 8

1) How do you examine chest expansion? What are you watching for?
2) What may unilateral expansion be a sign of?

Answer 8

1) Placing thumbs at lower costal boarder have pt inspire deeply, watch for symmetrical motion of both as the cavity expands or contracts
2) Chronic fibrosis of lung pleura, pleural effusion, hemidiaphragm paralysis

Question 9

1) What does diaphragmatic excursion test?
2) How should this be done, and what should be measured?

Answer 9

1) Diaphragmatic excursion tests how fully the lung is expanding
2) Do this using percussion, measuring the shift of the diaphragm posteriorly

Question 10

Describe how to measure diaphragmatic excursion.
1) Where should you percuss?
2) What does this identify?
3) What should you do next?
4) What should you note, and what should the measurement be?

Answer 10

1) Percuss from resonance to dullness post.
2) This identifies the boarder of the diaphragm and the bottom of the thoracic cavity when lungs are not inflated
3) Have patient take a deep breath and do the same
-Exhale fully and do the same
4) Note the difference
~3-5 cm

Question 11

1) What are tactile fremitus?
2) What are they normally?

Answer 11

1) Palpable vibrations that are transmitted through the pulmonary tree to the chest wall
2) Normally symmetric

Question 12

1) How do you check for tactile fremitus?
2) Where is it best felt?

Answer 12

1) Use ball, fingertips, or ulnar surface of hands to check for vibrations as the patient speaks (have pt say “99”)
2) Interscapular area; disappears beneath the diaphragm

Question 13

1) When is fremitus decreased?
2) What does this point to?
3) Give examples

Answer 13

1) Decreased when there is impediment of wave transmission
2) Thus, decreased transmission points either to too much mass or a lack of “connection”
3) Effusion or neoplasm (too much mass), PTX (cuts off connection to surface)

Question 14

1) Increased transmission of tactile fremitus is seen in what condition?
2) What else would be present w this condition?

Answer 14

1) PNA
2) Jiggly jangly bits of exudate, puss, and gunk

Question 15

1) During percussion, what can dullness replace? When?
2) What conditions is this indicative of?
3) What is hyperresonance indicative of?
4) How can you remember what causes dullness and what causes hyperresonance?

Answer 15

1) Dullness replaces resonance when fluid or solid tissue replaces air containing space
2) Lobar PNA, pleural effusion, hemothorax, empyema
3) Hyperinflated lungs of COPD (emphysema type), PTX, air-filled bulla
4) Drums are loud because they’re hollow

Question 16

What are the two intercostal spaces you should palpate? Describe each

Answer 16

1) Anterior
-Manubrium > sternal notch > 2nd rib > 2nd intercostal space
-3rd, 4th, 5th, 6th, etc.
2) Posterior
-12th rib > 11th space
-10th, 9th, 8th, etc.

Question 17

1) What is a flat sound like? What is its pitch and where do you hear it?
2) What is a dull sound like? What is its pitch and where do you hear it?
3) What is a resonant sound like? What is its pitch and where do you hear it?

Answer 17

1) Soft/short duration, high pitch, thigh
2) Medium loudness, middle pitch, liver
3) Getting loud/ medium duration, low pitch, healthy lung

Question 18

1) What is a hyperresonant sound like? What is its pitch and where do you hear it?
2) What is a tympanitic sound like? What is its pitch and where do you hear it?

Answer 18

1) Loud/ longer duration, lower pitch, PTX
2) Loud, high pitch, gastric air bubble or puffed out cheek

Question 19

1) How many places should you auscultate on the chest?
2) What about the back?

Answer 19

1) 6
2) 7

Question 20

1) How should a pt be breathing when you’re listening to their lung sounds?
2) What direction should you move in? why?
3) What should you listen for each time?

Answer 20

1) With their mouth open
2) Go horizontally, you are not only listening; you are also comparing one side to the other
3) Listen to one full breath each time

Question 21

Auscultation:
1) What pace should you perform it at?
2) Where are sounds louder? What should you do if this is not the case?
3) What could this indicate?

Answer 21

1) Go at their pace – not “breathe every time I move my stethoscope”
2) Usually, sounds are louder in the posterior lungs – if not, pay attention
3) Respiratory muscle weakness, COPD, effusion, ptx

Question 22

What are bronchovesicular or bronchial breath sounds caused by?

Answer 22

Embedded airways that are blocked by inflammation or secretions

Question 23

What are the 3 techniques to assess bronchovesicular or bronchial breath sounds? Describe each

Answer 23

1) Egophony: say “ee”
-You will hear “aaah”
2) Bronchophony: say “ninety-nine”
-You will hear these loudly, instead of being muffled (due to the jangly bits like in tactile fremitus)
3) Whispered pectoriloquy: have the pt whisper “ninety-nine”
-If you can hear it distinctly, you have demonstrated transmitted voice sounds again

Question 24

Presence of egophony, bronchophony, and whispered pectoriloquy, plus a fever, does what?

Answer 24

Triples the likelihood of pneumonia

Question 25

Define vesicular

Answer 25

The largely normal breath sounds

Question 26

1) Describe vesicular breath sounds
2) What do you hear more of? What are you not likely to pick up?
3) How do spoken words sound like? What does “ee” sound like?
4) What do whispered words sound like?
5) Is there tactile fremitus?

Answer 26

1) Pretty soft
2) You hear more inspiration than expiration
-Not likely to pick up transmitted voice sounds on this patient
3) Spoken words will sound muffled and distinct; “ee” will sounds like “ee”
4) Whispered words will remain indistinct
5) You probably won’t pick up much tactile fremitus on this patient

Question 27

1) What are “Broncho-vesicular” sounds like?
2) Describe the ratio of inspiration to expiration sounds
3) Where are they heard more? What indicates pathology?

Answer 27

1) Getting louder
2) Inspiration and expiration almost equal
3) In the first and second costal interspaces; when you hear them elsewhere that indicates pathology

Question 28

1) What can broncho-vesicular sounds indicate?
2) What is this?

Answer 28

1) Think of an air-filled lung; that has become a consolidated lung
2) Consolidation: Think of the way a skin wound looks i.e.,
i.e., pneumonia

Question 29

What may patients with a consolidated lung display?

Answer 29

1) Transmitted voice sounds; “ee” > “ah”
2) Spoken words are distinct through your stethoscope
3) Whispered sounds louder and clearer
4) Increased fremitus
5) You may also discover dullness to percussion

Question 30

1) Describe the volume of bronchial sounds
2) Are expiratory and inspiratory respiratory sounds the same or different?
3) Where is it heard?

Answer 30

1) Getting loud
2) Expiratory sounds last longer than inspiratory ones
3) Normally over manubrium and large, proximal airways

Question 31

1) What should you think when you hear bronchial signs when you’re listening anywhere besides the manubrium or large proximal airways?
2) Would other supportive PE findings match as well?

Answer 31

1) Follow the same thinking as you would in displaced broncho-vesicular sounds; air > consolidation
2) Would be likely to match as well; transmitted voice sounds, fremitus, etc.

Question 32

1) Describe the volume of tracheal breath sounds
2) Describe the inspiratory and expiratory phase
3) What is the pitch like?
4) Where are these sounds heard?

Answer 32

1) Very loud
2) Inspiratory and expiratory phase is about the same
3) Higher pitched
4) Over the trachea and neck

Question 33

Define adventitious sounds. Are they important?

Answer 33

“Added” breath sounds; an important finding

Question 34

1) What are rales?
2) What do they sound like?
3) What two conditions are they heard in?

Answer 34

1) Crackles
2) Like little dots, like snap crackle pop
3) HF, fibrosis

Question 35

1) What are ronchi?
2) What are they also called?
3) What two conditions are they seen in?
4) What causes them?

Answer 35

1) Low-pitched, rough sounds
2) Jankey lung
3) Bronchitis, COPD
4) Congestion from secretions in airway, can sometimes be cleared from coughing

Question 36

1) Define wheezing
2) What does it sound like?
3) When is it heard? Give 2 examples

Answer 36

1) Wheezing (it’s in the name)
2) High-pitched, sometimes musical sounding noise, whistley
3) Heard in “tight” airways; seen in asthma, respiratory distress

Question 37

What should you think if a pt’s breathing/ chest is silent?

Answer 37

Ominous; you need air movement to make sound

Question 38

Give 4 examples of adventitious sounds

Answer 38

1) Rales
2) Ronchi
3) Wheezing
4) Silent chest

Question 39

Describe fine crackles in terms of:
1) Pitch
2) What point in breathing it happens
3) What it sounds like
4) Why it sounds like this
5) What it’s heard in

Answer 39

1) Higher in pitch
2) Mid-to late inspiration
3) Velcro peeling open
4) Tiny airways pop open that had been stuck shut during previous inspiration
5) Seen in fibrosis, early CHF exacerbation

Question 40

Describe coarse crackles in terms of:
1) Duration
2) Pitch
3) What is occurring?
4) What it’s seen in

Answer 40

1) Longer duration
2) Lower pitch
3) Seen in COPD, HF (I think these sound a little lighter to heavier, depending on severity)
4) Opening and closing airways, letting gas move through