Pulmonary exam review

Question 1

How to count the ribs?

Answer 1

● Be able to count the ribs by
finding the sternal angle.
○ The adjacent rib is the 2nd

Question 2

After an Initial Survey of your patient, the following sequence is considered appropriate

Answer 2

○ Inspection
○ Palpation
○ Percussion
○ Auscultation

Question 3

Initial Survey includes:

Answer 3

● 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.

Question 4

Inspection of the thorax includes

Answer 4

● 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.

Question 5

This Can be indicative of a
chronic lung disease

Answer 5

nail clubbing

Question 6

Neck inspection

Answer 6

● Inspect the neck for
any signs of accessory
muscle contraction.
○ SCM
○ Scalenes
● Are there
supraclavicular retractions?
● Is the trachea at midline? Why

Question 7

Inspecting A-P diameter importance

Answer 7

● This can increase with aging, or
may be a sign of chronic obstructive lung
disease.

Question 8

Palpation of the thorax includes

Answer 8

● 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

Question 9

Several pathologic conditions can cause unilateral decreased chest expansion, or a delay in chest expansion, including:

Answer 9

○ Chronic Pulmonary Fibrosis
○ Pleural effusion
○ Significant lobar pneumonia
○ Pneumothorax
○ Unilateral bronchial obstruction

Question 10

Tactile Fremitus

Answer 10

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.”

Question 11

You may feel Increased Fremitus in

Answer 11

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

Question 12

You may feel Decreased Fremitus in

Answer 12

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

Question 13

This test measures the descent
of the diaphragm

Answer 13

Diaphragmatic Excursion

Question 14

An abnormally high level of dullness on one side suggests pathology:

Answer 14

● Could be a large pleural effusion.
● Could be high diaphragm as in
atelectasis or diaphragm paralysis

Question 15

Auscultation of the lungs involves:

Answer 15

1. Listening to sounds generated by
   breathing.
2. Listening for “added” adventitious sounds.
3. If adventitious sounds are present, consider
   performing some special tests.

Question 16

Adventitious (added/extra) Sounds

Answer 16

○ Wheezing
○ Crackles (Rales)
○ Rhonchi
○ Stridor
○ Friction Rubs

Question 17

Tracheal Breath Sounds

Answer 17

● 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

Question 18

Bronchial Breath Sounds

Answer 18

● 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

Question 19

Vesicular Breath Sounds

Answer 19

● 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

Question 20

If Bronchial (or Bronchovesicular) sounds are heard over lateral lung regions (where Vesicular sounds should be) what could this mean?

Answer 20

○ 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

Question 21

Occur when air flows rapidly through bronchi that are narrowed nearly to the point of closure

Answer 21

Wheezing

Question 22

Common causes of wheezing

Answer 22

asthma, COPD, congestive heart failure, and sometimes pneumonia

Question 23

Crackles (Rales) sounds

Answer 23

● 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”)

Question 24

Causes of crackles (Rales)

Answer 24

Interstitial lung disease, pulmonary edema of congestive heart failure, pneumonia, and sometimes COPD/asthma

Question 25

Rhonchi

Answer 25

● Rhonchi are course, relatively low-pitched sounds
that have a distinct “snoring” quality.
○ Can be during inspiration and/or expiration

Question 26

The discovery of rhonchi suggests

Answer 26

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.

Question 27

Stridor

Answer 27

● Stridor is a high-pitched wheeze that is
entirely or predominantly inspiratory

Question 28

Stridor usually indicates:

Answer 28

● Usually indicates partial obstruction of the
trachea or larynx and demands immediate
attention
● Causes include Epiglottitis, Croup,
and foreign body obstruction

Question 29

Pleural Rub

Answer 29

● 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

Question 30

____ is usually confined to a very localized
region of the chest wall

Answer 30

A rub

Question 31

Causes of a pleural rub

Answer 31

● Causes include infection,
nearby cancer, and some
medications.

Question 32

two most common Transmitted
Voice Assessments:

Answer 32

○ Egophony
○ Whispered Pectoriloquy

Question 33

When will you hear the egophany “eeee”?

Answer 33

.
● 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

Question 34

Whispered Pectoriloquy normal vs. abnormal

Answer 34

● 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

Question 35

Bronchophony: what is it and when is it considered positive?

Answer 35

● 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.