Pulmonary exam review Flashcards
How to count the ribs?
● Be able to count the ribs by
finding the sternal angle.
○ The adjacent rib is the 2nd
After an Initial Survey of your patient, the following sequence is considered appropriate
○ Inspection
○ Palpation
○ Percussion
○ Auscultation
Initial Survey includes:
● An initial survey should take only a few
seconds to complete, and is simply based
on your initial gestalt.
● Are they breathing well, choking,
coughing, tripoding, in respiratory
distress?
● Observe the patient’s respiratory rate,
rhythm, depth, and effort of breathing.
Inspection of the thorax includes
● From a midline position in front of or
behind the patient, note the shape of the
chest and how the chest moves.
● Assess for…
○ Any deformities or asymmetry.
○ Abnormal retractions in the
interspaces with inspiration.
○ Impaired respiratory movement on
one or both sides
● Assess for peripheral and central cyanosis
● During a pulmonary exam, always check for
nail clubbing.
This Can be indicative of a
chronic lung disease
nail clubbing
Neck inspection
● Inspect the neck for
any signs of accessory
muscle contraction.
○ SCM
○ Scalenes
● Are there
supraclavicular retractions?
● Is the trachea at midline? Why
Inspecting A-P diameter importance
● This can increase with aging, or
may be a sign of chronic obstructive lung
disease.
Palpation of the thorax includes
● Ask the patient if they have any areas of tenderness.
○ Carefully palpate tender regions or areas where bruising is evident
● Acute tenderness to palpation over pectoral
muscles or at the costal cartilage corroborate,
but do not prove, that the chest pain has a
musculoskeletal origin
Several pathologic conditions can cause unilateral decreased chest expansion, or a delay in chest expansion, including:
○ Chronic Pulmonary Fibrosis
○ Pleural effusion
○ Significant lobar pneumonia
○ Pneumothorax
○ Unilateral bronchial obstruction
Tactile Fremitus
Fremitus refers to the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient speaks
● Palpate and compare symmetric
areas as the patient repeats the words
“ninety-nine.”
You may feel Increased Fremitus in
Conditions that make the lung more dense
so vibrations are transmitted more easily.
Examples:
Pulmonary edema
pneumonia
Heavy bronchial secretions
Solid mass within the lung
You may feel Decreased Fremitus in
Conditions that make the lung less dense or
pull the lung away from the thoracic wall.
Examples:
Overexpansion (emphysema)
Pneumothorax
Pleural effusion
Increased body fat
This test measures the descent
of the diaphragm
Diaphragmatic Excursion
An abnormally high level of dullness on one side suggests pathology:
● Could be a large pleural effusion.
● Could be high diaphragm as in
atelectasis or diaphragm paralysis
Auscultation of the lungs involves:
- Listening to sounds generated by
breathing. - Listening for “added” adventitious sounds.
- If adventitious sounds are present, consider
performing some special tests.
Adventitious (added/extra) Sounds
○ Wheezing
○ Crackles (Rales)
○ Rhonchi
○ Stridor
○ Friction Rubs
Tracheal Breath Sounds
● Heard over the Trachea in the neck.
● The intensity of the sound is very loud.
● The pitch is relatively high.
● Inspiratory and Expiratory sounds are
about equal in pitch, intensity, and
duration
Bronchial Breath Sounds
● Heard best over the manubrium and
in the first and second interspaces
● Pitch is relatively high
● Expiratory sounds last slightly longer
than the Inspiratory sounds
Vesicular Breath Sounds
● Heard over most of both lung fields,
both anteriorly and posteriorly
● The intensity is soft
● The pitch is relatively low compared to
tracheal and bronchial sounds
● Inspiratory sounds last longer than Expiratory
sounds
If Bronchial (or Bronchovesicular) sounds are heard over lateral lung regions (where Vesicular sounds should be) what could this mean?
○ This suggests that normal air-filled
lung may have been replaced by
fluid-filled or solid lung tissue.
○ This is often the case in lobar
consolidation pneumonia
Occur when air flows rapidly through bronchi that are narrowed nearly to the point of closure
Wheezing
Common causes of wheezing
asthma, COPD, congestive heart failure, and sometimes pneumonia
Crackles (Rales) sounds
● Rales have two essential explanations:
○ When bronchioles and alveoli that deflate during expiration pop open during inspiration.
○ When air bubbles flow through secretions or lightly closed airways during respiration
● Sounds like discontinuous crackles or popping (“snap, crackle, pop”)
Causes of crackles (Rales)
Interstitial lung disease, pulmonary edema of congestive heart failure, pneumonia, and sometimes COPD/asthma
Rhonchi
● Rhonchi are course, relatively low-pitched sounds
that have a distinct “snoring” quality.
○ Can be during inspiration and/or expiration
The discovery of rhonchi suggests
the presence of abnormal secretions in bronchi and perhaps even bronchioles
● Common causes include pneumonia, COPD
exacerbations, Cystic Fibrosis, and bronchitis.
● In COPD or bronchitis, rhonchi often clear with coughing.
Stridor
● Stridor is a high-pitched wheeze that is
entirely or predominantly inspiratory
Stridor usually indicates:
● Usually indicates partial obstruction of the
trachea or larynx and demands immediate
attention
● Causes include Epiglottitis, Croup,
and foreign body obstruction
Pleural Rub
● Inflamed pleura often becomes rough and the two layers will rub together during respiration
● This increased friction is often heard as a
“creaking,” sandpaper-like sound.
○ Resembles crackles acoustically, but more
“creaky” and in both phases of respiration
____ is usually confined to a very localized
region of the chest wall
A rub
Causes of a pleural rub
● Causes include infection,
nearby cancer, and some
medications.
two most common Transmitted
Voice Assessments:
○ Egophony
○ Whispered Pectoriloquy
When will you hear the egophany “eeee”?
.
● In conditions like lobar consolidation pneumonia, you may hear a nasally “ay” instead of “eeee.”
● This E-to-A change is known
as Egophony, and is an abnormal Transmitted Voice finding and suggests fluid-filled (or pus-filled) region of lung
Whispered Pectoriloquy normal vs. abnormal
● Normally, the whispered voice is heard indistinctly
and faintly, if at all.
● Hearing louder, more clear whispered sounds is
abnormal, and called Whispered Pectoriloquy.
● Just like Egophony, this finding occurs in
conditions like lobar
consolidation pneumonia
Bronchophony: what is it and when is it considered positive?
● Auscultate the lung fields while your patient states (not whispers) “ninety nine.”
● Bronchophony is considered positive if you hear “ninety nine” as louder and more clear voice sounds, almost like normal.
● Similar to the first two, this occurs in consolidation or other more-dense lung situations.
