OSCE 11 - Lower Resp. Exam - Nov. 17, 2015 Flashcards
Lines we care about when inspecting chest
Anterior/posterior/ midaxillary line - ant. and pos. drop vertically from pos. axillary folds. Midaxillary from apex of the axilla
Midsternal line and midclavicular line - midsternal from the suprasternal notch. midclavicular form the midpoint of the clavicle
sternal angle occurs where..
2nd rib meets w/ the manubrium and the body of sternum
needle decompression landamrks
2nd intercostal space just superior to the 3rd rib margin (n.v. bundle is inferior to each rib) at midclavicular line for emergent decompression tension pneumothorax
-followed by chest tube placement
chest tube insertion landmark
4th intercostal space at mid/ anterior axillary line in the 4th intercostal space just superior to the margin of the 5th rib
T4 relevance
lower margin of endotracheal tube on chest x-ray
7th intercostal space
landmark for thoracentesis
evaluation of respiration (rate, rhythm, depth and effort)
healtht rat 14-20 / min
- note assymmetry, intercostal retractions
- cyanosis (hypoxia)
- breathing (audible wheezing etc.)
- pursed lips while breathing (obstructive lung dz.)
- patients with obstructive lung disorders tend to sit leaning forward with shoulder elevated
- neck inspection - contraction of accessory muscles (sternomastoid, scalenes or supraclavicular retraction)
tracheal position - should be midline (ex. lateral displacement of the trachea can occur in tension pneumothorax)
fingernail clubbing description, mechanism
- bulbous swelling of soft tissue at nail base
- loss of normal angle between nail and proximal nail fold (>180 degrees) leading to spongy/ floating feeling
- mech. may involve vasodilation, changes in ct. tissue, innervation or PDGF form platelet clump fragments
clubbing of fingernails indicative of
seen in congenital heart dz, interstitial lung dz, lung cancer, cystic fibrosis
focus on these when palpating chest
- areas of tenderness abnormalities in - overlying skin - resp. expansion - tactile fremitus
how do you check thoracic expansion?
place thumbs at level of 10th ribs
- fingers loosely grasping and parallel to the lateral rib cage
- patient inhales deeply
- watch thumbs as they move apart during inspiraiton, feel for range/ symmetry as rib cage expands and contracts
how do you check tactile fremitus
- performed on ant. post. chest
- palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as patient speaks “ninety nine” or “one-one-one”
- follow pattern to right
where is tactile fremitus most prominent?
- more prominent in the interscapular area than in the lower lung fields
- more prominent on the right than left
- disappears below diaphragm
decreased/ absent fremitus indicates
COPD pleural efusions fibrosis pneumothorax infiltrating tumor
increased fremitus indicates
pneumonia - increased transmission through consolidated tissue
why do we percuss the chest?
to establish if underlying tissues are
- air filled
- fluid filled
- solid
technique for percussing chest
- hyperextend middle finger and have only this finger firmly contact skin
- strike extended finger at DIP
- start superiorly percussing both sides of chest working toward base proceeding in a “ladder-like” pattern
- also done on anterior chest
learn to identify these five percussion notes:
flat dull resonant hyperresonant tympanitic
percussion and auscultation pattern for posterior thorax
- patient seated with both arms crossed in front of chest
- percuss/ ausc. thorax in symmetric locations
generalized hyperresonance may be heard over hyperinflated lungs in
COPD
asthma
unilateral hyperresonance suggests
- large pneumothorax
- large air-filled bulla in lung
dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies space beneath percussing fingers and may indicate these pathologies
- lobaer pneumonia (alveoli filled w/ fluid and blood cells)
- pleural /accumulations:
= Effusion (serous fluid)
= hemothorax (blood) [treated w/ chest tube]
= empyema (pus)
= fibrous tissue/ tumor
diaphragmatic excursion - how to check and normal
- determine distance between level of dullness on full expiration and level of dullness on full inspiration by progressive percussion down from resonance (lung parenchyma) to dullness (structures below diaphragm)
- normal excursion = 3 to 5.5 cm
auscultation involves
listening to normal sounds generated by breathing
- listening for any adventitious (added) breath sounds
- if abnormality suspected ,listen to sounds of patients spoken or whispered voice
normal breath sounds: vesicular
- soft and low pitched
- heard through inspiration and about 1/3 of expiration
- heard over most of lungs (parenchyma)
normal breath sound: bronchovesicular
- intermediate in intensity and pitch
- heard equally in inspiration and expiration
- heard best in 1st and 2nd interspaces anteriorly and b/w the scapulae
normal breath sound: bronchial
- loud and high pitched
- exp. sounds heard longer than inspiratory
- heard best over manubrium (larger proximal airways)
normal breath sound: tracheal
- very loud and high pitched
- heard equally in insp. and exp.
- heard best over trachea in neck
if bronchovesicular or bronchial breath sounds heard more distal to expected locations, suspect..
air-filled lung has been replaced by fluid-filled or solid lung tissue
adventitious breath sounds
[superimposed on usual breath sounds]
- crackles (rales)
- wheezes and rhonchi
- stridor
- pleural friction rub
crackles (rales)
discontinuous; intermittent, nonmusical and brief
defined by:
fine crackles: soft, high-pitched, very brief (5-10 msec)
coarse crackles: louder, lower in pitch, brief (20-30 msec)
- timing in resp. cycle insp., exp. or mid-insp./ exp.
wheezes and rhonchi general description.
continuous; musical quality and prolonged (not necessarily the entire resp. cycle)
wheezes description; indicates?
relatively high pitched, musical, hissing or shrill quality
- suggest narrowed airways (asthma, COPD, bronchitis)
rhonchi description; indicates?
- relatively low-pitched, snoring quality
- suggest secretions in large airways
stridor description
- wheeze that is entirely or predominantly inspiratory in nature
- often louder in neck vs. chest wall
- indicates partial obstruction of larynx or trachea (immediate attention needed)
pleural friction rub description
- inflamed and roughened pleural surfaces grate against each other as they are momentarily and repeatedly delayed by increased friction
- sounds like creaking, usually during exp. but can occur in both phases of respiration
- usually confined to a relatively small area of chest wall
if abnormally located bronchovesicular or bronchial breath sounds are heard (pneumonia, consolidations, effusions) you should..
assess transmitted voice sounds
patient says “99” while doc listens to lungs; if abnormal, can have..
normally sounds transmitted through healthy lungs are muffled and indistinct. (can also palpate tactile fremitus while patient speaking)
- BRONCHOPHANY: spoken words become louder and clear
patient says “ee”; if abnormal can have..
normally should hear muffled long E sound
- EGOPHANY: “ee” sounds like “a”
- “A” has nasal bleating quality and should be localized
in patients with fever and cough, the presence of bronchial breath sounds and egophony..
more than triples the likelihood of pneumonia!
patient whispers “ninety-nine” or “one-two-three”; if abnormal, can have..
- normally a whispered voice is faint and indistinct or not heard at all
- WHISPERED PECTORILOQUY: whispers are heard louder and clearer during auscultation
