Pulmonary

Question 1

the interspace is named for the rib above or below it?

Answer 1

above

Question 2

scapular inferior angle is located about where?

Answer 2

just under the 7th rib

Question 3

Costal cartilages of ______ articulate with the sternum

Cartilages of _____ articulate with costal cartilages just above

Answer 3

first 7 ribs

8-10

Question 4

______ are floating ribs

Answer 4

11 and 12th

Question 5

___is appreciated laterally (it is short so it does not come all the way around)
____ – is posterior – may use as posterior landmark to count ribs from bottom up

Answer 5

11: lateral
12: posterior

Question 6

______ needle insertion for tension pneumothorax
________-intercostal space for chest tube insertion
The tube is generally placed where it is needed.

Answer 6

2nd interspace - tension pneumo

4th or 5th interspace - chest rube

Question 7

_______ landmark for thoracentesis

Answer 7

T7-T8 interspace

Question 8

why do we insert just on top of the rib for chest tube?

Answer 8

The neurovascular structures run under the ribs so insert things on top of the rib…

Question 9

what are our 7 circumferential landmarks?

Answer 9

lines: midsternal, midclavicular, anterior axillary , mid-axillary, post-axillary, scapular (mid-scapular) and vertebral

Question 10

the apex of the lung is _____ above the _____

Answer 10

2-4 cm above the clavicle

Question 11

lower border of the lung crosses the ______ posterior it lines at about ___________

Answer 11

6th rib at midclavicular and 8th rib at midaxillary line , posteriorly lies at the level of the T10 spinous process but descends with inspiration

Question 12

oblique (the major) fissure of the _(right or left?)____ lung, starts at ___ and ends ____

Answer 12

right lung, starts at T3 and ends at 6th rib, midaxillary line
- this divides the lung in half

Question 13

the horizontal (minor) of the __(right or left?)_lung divides ______

Answer 13

right lung, divides upper lobe into two- into right upper and right middle

Question 14

the trachea bifurcates at …

Answer 14

the sternal angle anteriorly, at the T4 level posteriorly

Question 15

the conducting zone walls are line with ______ and include ____

Answer 15

smooth muscle, mucus secreting and ciliated cells

Question 16

Respiratory bronchioles are ______ with some smooth muscle and cilia and have a few alveoli

Answer 16

transitional

Question 17

______has an effect on the blood flow to the different areas in the lungs

Answer 17

gravity

Question 18

what pressure keeps the lungs inflated?

Answer 18

negative intrapleural pressure

Question 19

what are the receptors in the resp. center of the brainstem

Answer 19

chemoreceptors

Question 20

what are the primary (1) and accessory (5) muscles of breathing?

Answer 20

primary: diaphragm
accessory:
scalene (cervical vert. to first two ribs)
parasternal (sternum to ribs obliquely)
sternocleidomastoid
intercostals
abdominals

Question 21

what do the external vs internal intercostals do?

Answer 21

external: inhale
internal: exhale

Question 22

abdominal muscles assist in …

Answer 22

expiration

Question 23

what are the two pleura layers of the lung?

Answer 23

inner: Visceral pleura covers the outer surface of the lung
outer: Parietal pleura lines the lung cavity (rib cage and diaphragm)
- fluid between the two allow easy movement of lungs

Question 24

pleural effusions: transudates vs exudates

Answer 24

transudates: pressure problem-imbalance of hydrostatic and osmotic forces (i.e. atelectasis, HF)
exudates: injury or inflammation problem (ie pneumonia, PE)

Question 25

air trapped in pleural space?

Answer 25

pneumothorax - can be small or entire lung

Question 26

how can you recognize a Pneumothorax?

Answer 26

clinical, chest Xray

Question 27

technique for exam, for posterior exam if the pt can't sit up you can...

Answer 27

roll them from side to side - document that they were unable to sit

Question 28

technique for exam, anterior - easier to examine if pt is ...

Answer 28

lying down

Question 29

4 purposes of the lung and thorax exam

Answer 29

1. lung function 2. musculature- internal and external 3. skeletal 4. skin

Question 30

initial survey of breathing, examine ...

Answer 30

rate, rhythm, depth, effort

Question 31

inspection of the thorax

Answer 31

shape and condition of thorax: bony deformities, splinting (obviously favoring one lung over the other), asymmetry

Question 32

depression of lower part of sternum can cause what to the heart .... and is deemed the term ______

Answer 32

compression of heart and great vessels- may cause murmurs. Called Funnel Chest (pectus excavatum)

Question 33

what are the 3 possible reasons for barrel chest?

Answer 33

children, older people, COPD (from emphysema)

Question 34

Pectus carinatum, commonly known as ______, is caused by what anatomical abnormality?

Answer 34

pigeon chest- costal cartilages near protruding sternum are depressed - make it look like sternum is sticking out

Question 35

how does a flail chest present? common cause?

Answer 35

paradoxical movement of chest- injured area caves in with inspiration, out with expiration. From multiple rib fractures - car accident likely.

Question 36

how does thoracic kyphoscoliosis present?

Answer 36

curved spine anteriorly, one side of ribs spread wider and one sider ribs are closer

Question 37

what is "respiratory excursion"?

Answer 37

examining chest expansion (putting hands on either side of chest and pinching skin between)

Question 38

tactile fremitus

Answer 38

vibrations transmitted through the lung tissue when pt talks

Question 39

tactile fremitus- how many anterior and posterior areas do you examine? what about for percussion?

Answer 39

3 anterior, 4 posterior | percussion: 6 anterior, 7 posterior

Question 40

percussion is examining whether the tissue underneath is ______, ______ or ________

Answer 40

air-filled, fluid-filled, or solid

Question 41

diaphragmatic excursion - normal is _______. reduced will indicate ... absent will indicate...

Answer 41

normal: 3-5 cm reduced: emphysema absent: phrenic nerve palsy

Question 42

auscultation: what to note about breath sounds (3)

Answer 42

character, intensity (flow from mouth), presence of adventitious sounds

Question 43

breath through nose or open mouth for auscultation?

Answer 43

open mouth

Question 44

never auscultate ______

Answer 44

through clothing!

Question 45

auscultating the back... what is your process?

Answer 45

ask pt to cross arms in front of him, start on top and zig-zag your way down (right to left)

Question 46

tracheal sounds

Answer 46

loud, harsh, high-pitched heard over trachea and neck inspiratory = expiratory

Question 47

bronchial sounds

Answer 47

loud and high-pitches heard over manubrium (if at all) expiratory longer than inspiratory short silence between sounds

Question 48

bronchiovesicular sounds

Answer 48

intermediate -> low pitched - heard between 1st and 2nd interspaces anteriorly, scapula posteriorly - inspiratory = expiratory

Question 49

Vesicular sounds

Answer 49

soft, low-pitched - heard over most of the lung fields bilaterally - inspiratory longer than expiratory (which fades 1/3 of the way) - sounds heard posteriorly

Question 50

crackles/ rales

Answer 50

fine: like hair rubbing (from alveoli and terminal bronchioles) coarse: like crinkling cellophane (from bronchioles).

Question 51

you hear coarse crackles, what will you ask pt to do? why?

Answer 51

ask them to cough. If pt cant clear with a cough or sound is louder with cough- maybe fluid in the lung

Question 52

"fine" or "course" summarizes the _______, ________, and _______ of crackles

Answer 52

loudness, pitch, duration

Question 53

wheezes

Answer 53

high-pitched, musical

Question 54

whats important to remember when considering wheezing

Answer 54

sometimes person is so restricted that you can no longer hear the wheeze. BAD- no air moving through.

Question 55

stridor

Answer 55

a wheeze that entirely or majorly inspiratory, heard louder in the neck than in chest. Indicates partial obstruction of airway in neck, larynx, trachea.

Question 56

friction rub

Answer 56

sounds scratchy: inflamed surfaces move jerkily - theyre momentarily delayed by friction

Question 57

mediastinal crunch

Answer 57

"boot in dry snow" sound (hammans sign). | -precordial (over the heart) crackles with each heart beat and not respirations

Question 58

what causes a mediastinal crunch?

Answer 58

pneumomediastinum- air dissects along bronchus and mediastinum

Question 59

transmitted voice sounds: what are we looking for?

Answer 59

if you hear a change if means possible consolidation or other compression of lung tissue

Question 60

3 transmitted voice sound tests

Answer 60

bronchophony: "ninety nine" - more distinct sound egophony: "ee" to "ay" whisper pectoriloquy: "ninety-nin" whispered- gets louder and clearer.

Question 61

how many lobes in right and left lung?

Answer 61

3- right | 2 - left

Question 62

paroxysmal nocturnal dyspnea- how does it present and what causes it?

Answer 62

acute dyspnea appear suddenly at night - waking the pt. caused by pulm. congestion/edema from Left HF

Question 63

seven attributes

Answer 63

location, quality, quantity/severity, timing, setting, worsening/alleviating factors, associated manifestations

Question 64

chest pain.. can have multiple causes, so check...

Answer 64

system below and system below

Question 65

duration of cough: acute, subacute, chronic

Answer 65

acute: < 3 wks subacute: 3-8wks chronic: >8 wks

Question 66

what 3 things would have resonant sounds

Answer 66

``` normal lungs chronic bronchitis (but with coarse crackles, wheezes, rhonci) Left HF (but w/ inspiratory crackles) ```

Question 67

dull sounds could be what 3 causes?

Answer 67

consolidations (w/ bronchial sounds in involved area, late insp crackles, inc. transmitted voice sounds) atelectasis (w/ tracheal shift toward effected side, absent sounds, absent tactile F and transmitted sounds) pleural effusion: (w/ trachea to non-effected side, dec. breath sounds, maybe friction rub, possible increase tactile F and transmitted voice sounds over large effusion)

Question 68

what three things could cause hyperresonant sounds?

Answer 68

pneumothorax: hyperressonant/tympanic (w/ trachea shifted to unaffected side, decreased breath sounds, maybe tactile F and transmitted sounds) COPD (maybe w/ crackles,wheezes, rhonci) asthma (w/ wheezes and crackles)