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PCM 1 > OSCE 11 - Lower Resp. Exam - Nov. 17, 2015 > Flashcards

OSCE 11 - Lower Resp. Exam - Nov. 17, 2015 Flashcards

1
Q

Lines we care about when inspecting chest

A

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

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2
Q

sternal angle occurs where..

A

2nd rib meets w/ the manubrium and the body of sternum

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3
Q

needle decompression landamrks

A

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

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4
Q

chest tube insertion landmark

A

4th intercostal space at mid/ anterior axillary line in the 4th intercostal space just superior to the margin of the 5th rib

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5
Q

T4 relevance

A

lower margin of endotracheal tube on chest x-ray

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6
Q

7th intercostal space

A

landmark for thoracentesis

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7
Q

evaluation of respiration (rate, rhythm, depth and effort)

A

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)

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8
Q

fingernail clubbing description, mechanism

A
  • 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
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9
Q

clubbing of fingernails indicative of

A

seen in congenital heart dz, interstitial lung dz, lung cancer, cystic fibrosis

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10
Q

focus on these when palpating chest

A 
- areas of tenderness
abnormalities in
- overlying skin
- resp. expansion
- tactile fremitus
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11
Q

how do you check thoracic expansion?

A

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
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12
Q

how do you check tactile fremitus

A
  • 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
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13
Q

where is tactile fremitus most prominent?

A
  • more prominent in the interscapular area than in the lower lung fields
  • more prominent on the right than left
  • disappears below diaphragm
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14
Q

decreased/ absent fremitus indicates

A 
COPD
pleural efusions
fibrosis
pneumothorax
infiltrating tumor
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15
Q

increased fremitus indicates

A

pneumonia - increased transmission through consolidated tissue

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16
Q

why do we percuss the chest?

A

to establish if underlying tissues are

  • air filled
  • fluid filled
  • solid
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17
Q

technique for percussing chest

A
  • 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
18
Q

learn to identify these five percussion notes:

A 
flat
dull
resonant
hyperresonant
tympanitic
19
Q

percussion and auscultation pattern for posterior thorax

A
  • patient seated with both arms crossed in front of chest

- percuss/ ausc. thorax in symmetric locations

20
Q

generalized hyperresonance may be heard over hyperinflated lungs in

A

COPD

asthma

21
Q

unilateral hyperresonance suggests

A
  • large pneumothorax

- large air-filled bulla in lung

22
Q

dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies space beneath percussing fingers and may indicate these pathologies

A
  • 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
23
Q

diaphragmatic excursion - how to check and normal

A
  • 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
24
Q

auscultation involves

A

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
25
Q

normal breath sounds: vesicular

A
  • soft and low pitched
  • heard through inspiration and about 1/3 of expiration
  • heard over most of lungs (parenchyma)
26
Q

normal breath sound: bronchovesicular

A
  • intermediate in intensity and pitch
  • heard equally in inspiration and expiration
  • heard best in 1st and 2nd interspaces anteriorly and b/w the scapulae
27
Q

normal breath sound: bronchial

A
  • loud and high pitched
  • exp. sounds heard longer than inspiratory
  • heard best over manubrium (larger proximal airways)
28
Q

normal breath sound: tracheal

A
  • very loud and high pitched
  • heard equally in insp. and exp.
  • heard best over trachea in neck
29
Q

if bronchovesicular or bronchial breath sounds heard more distal to expected locations, suspect..

A

air-filled lung has been replaced by fluid-filled or solid lung tissue

30
Q

adventitious breath sounds

A

[superimposed on usual breath sounds]

  • crackles (rales)
  • wheezes and rhonchi
  • stridor
  • pleural friction rub
31
Q

crackles (rales)

A

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.

32
Q

wheezes and rhonchi general description.

A

continuous; musical quality and prolonged (not necessarily the entire resp. cycle)

33
Q

wheezes description; indicates?

A

relatively high pitched, musical, hissing or shrill quality

- suggest narrowed airways (asthma, COPD, bronchitis)

34
Q

rhonchi description; indicates?

A
  • relatively low-pitched, snoring quality

- suggest secretions in large airways

35
Q

stridor description

A
  • 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)
36
Q

pleural friction rub description

A
  • 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
37
Q

if abnormally located bronchovesicular or bronchial breath sounds are heard (pneumonia, consolidations, effusions) you should..

A

assess transmitted voice sounds

38
Q

patient says “99” while doc listens to lungs; if abnormal, can have..

A

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

39
Q

patient says “ee”; if abnormal can have..

A

normally should hear muffled long E sound

  • EGOPHANY: “ee” sounds like “a”
  • “A” has nasal bleating quality and should be localized
40
Q

in patients with fever and cough, the presence of bronchial breath sounds and egophony..

A

more than triples the likelihood of pneumonia!

41
Q

patient whispers “ninety-nine” or “one-two-three”; if abnormal, can have..

A
  • normally a whispered voice is faint and indistinct or not heard at all
  • WHISPERED PECTORILOQUY: whispers are heard louder and clearer during auscultation

PCM 1 (17 decks)

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