Respiratory CAS exam and Anatomy Flashcards
How do you palpate position of the trachea
Tell the pt that it will be a little but uncomfortable
Tell them to lean back and lower neck slightly
Put middle finger in suprasternal notch and use the 2 adjacent fingers to assess positions by moving it up.
What are the lung diseases that could occur due to displacement of trachea towards side of lesion
- Upper lobe collapse
- Upper lobe fibrosis
- Pneumonectomy
Wha are the common causes of tracheal displacement AWAY from the side of lung lesions
- Extensive pleural effusion
- Tension pneumothorax
What will movement of anterior chest give you an indication of?
How do you do this?
Expansion of upper and middle lobes of lungs
Put arm around 5th or 6th rib. Tell pt to take a deep breath and exhale.
Thumb shouldnt touch and should only be displaced by atleast 5 cm
What will expansion of posterior chest wall give an indication of?
Expansion of lower lobe of the lung
the chest expands both symmetrically on both sided during inspiration
Go below T10
Wha are the common causes of unilateral decreased expansion
- Pneumothorax
- Plaural effusion
- Collapsed lung
- Consolidation
Reduced expansion of chest wall on one side indicates a lesion on that side
What are the causes of Bilateral decrease in expansion
Asthma or COPD
very difficult to detect
What are the suggested percussion/auscultation areas?
what do you have to tell females to do during examinations
May have to tell female to move breat laterally- DO NOT PERCUSS THE BREAST tissue
Anterior - sit on chair at 45 degrees
- Apex
- 3 ics, 5 ics and 7 ICS MAL
Posterior- sit on edge of bed
- Trapezeius
- Above T3
- Around T10
Do both sides
What is hyper resonant percussion note and what could cause it
Hollow spaces such as pneumothorax or hollow bowels
pateints with COPD
What pathology could cause hyporesonant percussion note
Pleural effusion - causes stoney dull sound
solid tissue like tumour, consolidation or collapse lung
What are the factors that will affect sound of percussion note
Thickness of chest walls muscles
overlying bony structures
What are normal structures in body that will give hyporesonant percussion notes
Liver
Heart
What are the bronchial sounds and where can you auscultate them
High pitched sound- air turbulence is heard without filtering. Inspiration sound is the same sound as expiration sound duration
Heard over:
- trachea
- sternal angle and sternoclavicular joints
airway isn’t surrounded by alveolar tissue hence no filtering
What is vesicular sound and where can you hear them
Low pitched sound present all over rest of chest area where normal lung tissue is present
Lung tissue filters the sounds of air turbulence - hence air is not turbulent
How do you test Tactile Vocal Fremitus?
- Ask the patient to say “ninety nine”
- Palpate across the chest wall with your hands
- You should feel the vibrations equally in both hands
Do anterior and posterior
What are the characteristics of vesicular sound breath
- Soft, low pitched, and rustling in quality
- Inspiratory phase lasts longer than the expiratory phase
- Intensity of inspiration is greater than that of expiration
- Inspiration is higher pitch than expiration
- No pause between inspiration and expiration
What are the causes of reduced intensity of vesicular breath sound ?
what are the causes of prolonged expiration
- Shallow breathing
- airway obstruction
- hyperinflation
- pneumothorax
- pleural effusion
- pleural thickening
- obesity
in Obstrucitve disease like chronic bronchitis and asthma, expiration becomes prolonged
What are the characteristics of bronchial breat sounds and where can you hear it
- It is loud, hollow, and high pitch
- Expiratory phase is longer than the inspiratory
- There is distinct pause between inspiration and expiration.
It is normally heard over the manubrium and interscapular area , trachea . Posteriorly between C7 and T3
What pathology will cause bronchial breath sounds to be heard?
Consolidation
Localised pulmonary fibrosis
pleural effusion
collapsed lungs
What is the indication of giving chest drain
Pneumothorax
Pleural effusion
Hameothorax
Where is the safe space and prodceure to insert chest drain
What is the procedure for performing a tracheotomy
This is an Opening created on anterior wall of trachea between 1st and 2nd trachea cartilage
retract infrahyoid muscle laterally an retract thyroid isthmus laterally/divide supeirorly
tube is inserted into opening and secured
What are the indications for performing a tracheostomy
Patients with upper airways obstruction or respiratory failure
What is the ANTERIOR surface marking for RIGHT PARIETAL PLEURA
- A- APEX of pleura- in root of neck above medial 1/3 of clavicle
- B- just over sternoclavicular joint
- C-just right of AML at centre of sternal angel
- D-just right of AML of 4th costal cartilage
- E- just right of AML at level of 6th CC
- F- MCL at level of 8th rib- can access from costal margin
What are the POSTERIOR margins of right parietal pleura
- G- Mid axillary line at level of 10th rib
- H- where scapular line crosses 12th rib
- I- transverse process of L1- subcostal below 12th rib
- J- transverse process fo T1 vertebrae
What are the margins for LEFT parietal pleura
Same as right parietal pleura EXCEPT
- D and E WHERE IT DELFECTS SHARPLY for cardiac notch
What is the procedure for measuring chest expansion
Anterior: patient is lying 45 degrees on bed
tell patient to take a deep breath and out then hold ribs with hands and thumbs should move freely at AML jus below 5th and 6th rib
Thumb shoud deviate around 5cm from each other as chest expands during normal inspiration
Posterior- at level of T10
What are the positions for percussion
Anterior chest wall percussion - both sides
- apex
- infraclavicular
- 2nd-6th intercostal spaces
Posterior chest wall percussion area
- trapezius
- level of scapula spin
- level of 10th/11th ribs
What is the procedure for auscultation of chest wall- lungs
Anterior
- Auscultate apex with bell of stethoscope
- Auscultate with diaphragm down to 6th rib and laterally to 8th rib
Posterior
- form trapezius down to level of 11th rib- check each lobe of the lungs
last let check Tactile vocal fremitus
What is the projection margin of the right lungs
Follows parietal pleura until level E then:
- f- MCL at 6th rib
- g- MAL at 8th rib
- h- scapular line at 10th rib posteriorly
- I- T12 level posteriorly
What are the margins of the oblique fissure for both lungs
OF1) Posteriorly at the level of spine of 3rd thoracic vertebra (T3)
OF2) Anteriorly at the lower border of the lung at the junction of the 6th costal cartilage and MCL.
Connect these two points by a smooth curved line running around the lateral thoracic wall. This line represents the oblique fissure.
What are the margins for the horizontal fissure
Palpate 4th CC on the right and draw a line along 4th CC and 4th rib laterally to meet oblique fissure in MAL
What are the lung margins of the left lung
1) The outline for the left lung is same as for the right lung except for the mediastinal reflection below the 4th costal cartilage
2) Below the 4th costal cartilage, the cardiac notch deviates by 2-3 cm lateral at the level of 5th costal cartilage.
3) The lower border of the left lung follows the same course as the right lung.
what are the causes of increased or decreased tactile fremitus
Decreased: due to decrease in density . E.g:
- Pnuemothorax
- COPD
- Pleural effusion due to increased distance between chest wall and lungs
Increased- increase in density due to:
- Consoloidation in pnuemonia
- Tumour in cancer
what are the respiratory causes of cervical lymph node lymphadenopathy
Malignancy
Infection
what lymph nodes should you palpate and in what order.
Do it in circular motion
- Submental nodes –inferior to the chin
- Submandibular nodes –inferior to the angle of the mandible
- Preauricular/parotid nodes
- Postauricular nodes - posterior to the ear
- Occipital nodes - base of the occipital
- Superior deep cervical nodes - superior part of the sternocleidomastoid
- Inferior deep cervical nodes - inferior part of the sternocleidomastoid
- Supraclavicular nodes - superior to the clavicle
Summarise the intermediate respiration examination order
- Position and exposure: Patient lying at 45 degrees, exposed from the waist upwards
- Inspection: General inspection
- Palpation: Tracheal position
- Anterior chest expansion
- Anterior chest percussion
- Anterior chest auscultation
- Anterior tactile vocal fremitus
- Position: Patient leaning forwards
- Posterior chest expansion
- Posterior chest percussion
- Posterior chest auscultation
- Posterior tactile vocal fremitus
- Position: Patient sitting across couch
- Cervical lymph node palpation
what are the red and blue lines pointing towards in this CXR and explain why?
Pt with pneumonia
Blue- increased opacification:
- There’s consolidation as small airways and alveolar spaces filled with pus, fluid, dead cells.
- Material denser than air and appear white
Red- Air bronchogram:
- in consolidated tissue, some small airways still filled with air and hence looked dark superimposed over increased opacification
why are borders lost on CXRs
Silhouette sign
When alveolar tissues next to strucute is filled with material more dense thasn air
Material attenuates x-ray similar to adjacent strucutres like heart
what are some of the exam findings a d X-ray for CAP
- Tachypnoea
- Bronchial breathing
- crackles
- Dullness to percussion
X-ray:
- Increased opacification
- Air bronchograms
- Silhouettes sign
what are the possible clinical signs of of a pneumothorax?
