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Exam 2 > Respiratory Module > Flashcards

Respiratory Module Flashcards

1
Q

In recording the amount of cigarette smoking that a patient does and has done

A

measure the quantity of cigarette exposure in terms of packs-years

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2
Q

To calculate packs-years

A

it is the number of packs of cigarettes (20 per pack) a person smokes per day multiplied by the number if years he has smoked that many

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3
Q

The thorax has 4 surfaces, each of which deserves attention during the course of the physical exam:

A
  1. ) Anterior surface- between the 2 axillary lines
  2. ) Posterior surface - b/t2 posterior axillary lines
  3. ) Lateral surface - b/t the anterior and posterior lines bilaterally
  4. ) Supraclavicular surface - above the clavicles bilaterally
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4
Q

The thorax is divided horizontally by the

A

ribs and the interspaces

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5
Q

Each interspace is named (numbered) by the

A

number of the rib right above it. It is further referred to as either right or left.

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6
Q

It should be noted that on physical exam, the highest rib that can be palpated on the anterior surface of the chest is

A

the second rib

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7
Q

The 1st interspace that can be identified on the anterior surface of the chest is the

A

second interspace

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8
Q

The first rib and the first interspace are

A

“hidden” beneath the clavicle and cannot be detected on physical examination

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9
Q

Ribs and interspaces are easily detected on the anterior and lateral surfaces of the thorax but

A

are more difficult to detect on the posterior surface of the thorax

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10
Q

Using the ribs as real horizontal lines, the thorax can be divided into a

A

grid of sorts by using a system of imaginary vertical lines that intersect the ribs at specified points

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11
Q

The imaginary lines are:

Mid-sternal line

A

A line extending from the suprasternal notch in the anterior midline of the neck to the tip of the xyphoid process. It bisects the sternum.

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12
Q

Parasternal lines (right and left)

A

Lines that run vertically down each side of the sternum, joining the points at which the ribs (costal cartilages) meet the sternum

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13
Q

Mid-Clavicular lines (right and left)

A

Lines which extend from the mid-point of each clavicle to the mid-point of each anterior costal margin bilaterally. These lines generally intersect the nipples on each side and are occasionally referred to as the nipple lines

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14
Q

Anterior axillary lines (right and left)

A

Lines which extend down along each anterior axillary fold bilaterally and which parallel the mid-sternal and mid-clavicular lines

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15
Q

Mid-Axillary lines (right and left)

A

lines which extend vertically down from the apex of each axilla bilaterally and which parallel the anterior and posterior axillary lines

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16
Q

Posterior axillary lines (right and left)

A

lines which extend downward along the posterior axillary folds

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17
Q

Mid-scapular lines (right and left)

A

lines that extend through the inferior tip of the scapulae bilaterally. These lines are parallel to the thoracic spine and the mid-spinal line

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18
Q

Mid-spinal line (or vertebral line)

A

A line extending from the spinous process of the seventh cervical vertebrae to the spinous process of the 1st lumbar vertebrae. It intersects the spinous processes of each of the thoracic vertebrae. This line is straight in patients with a normal spine but may be curvilinear in patients with scoliosis.

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19
Q

The muscles utilized in the act of ventilation are divided into groups:

A
  1. ) the main muscles of respiration

2. ) the accessory muscles of respirations

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20
Q

The diaphragm and occasionally the external intercostal muscles are the

A

main muscles of respiration and are only needed during the act of inspiration to inflate the lungs. During expiration, all these muscles do is relax.

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21
Q

The accessory muscles of respirations are not needed to any extent during

A

non-labored breathing but become very necessary for both inspiration and expiration in patients with labored breathing.

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22
Q

In patients with labored inspiration, the accessory muscles utilized are the

A

sternocleidomastoid, scalenus, the pectoralis minor, and greater effort from the external intercostal muscles.

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23
Q

In patients with labored expiration, accessory muscles required for forced expiration include

A

the abdominal muscles (rectus abdominus) and the internal intercostals.

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24
Q

Angle of Louis (or sternomanubrial junction)

A

a bony prominence projecting forward on the anterior surface of the sternum about 2 inches (5cm) below the suprasternal notch

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25
Q

Angle of Louis is the fixed joint b/t the manubrium and the sternum and marks the site at which the

A

second rib (second costal cartilage) joins the sternum. it is a convenient landmark with which to locate the 2nd intercostal space

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26
Q

Costal Angle

A

the angle formed at the site of the xiphoid process by the intersecting costal margins.

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27
Q

The costal angle is measured in

A

degrees (normally the costal angle is 90 degrees or less)

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28
Q

Anterior-Posterior (A-P) Diameter

A

The distance b/t the sternum and the spine; it is usually “measured” as to how it relates to the lateral diameter of the chest at its widest point

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29
Q

4 techniques of physical assessment are used for chest examination:

A
  1. ) inspection
  2. ) palpation
  3. ) percussion
  4. ) auscultation
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30
Q

Structures outside of the thoracic region that relate to respiratory function and should be examined are:

A

the nose for nasal flaring, the position of the trachea in the neck, the color of the skin of the fingertips and around the mouth, the structure of the fingernails, etc.

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31
Q

The thorax and lungs can be examined with the patient sitting

A

up (preferable) or lying down

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32
Q

The thorax can be visualized in layers, consisting of a

A

skin layer, a muscle layer, a bone layer, and lung layer.

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33
Q

In examining the surface of the thorax, the examiner should attempt to relate surface findings to

A

underlying lung structure

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34
Q

For a complete evaluation of the thorax, the patient should be

A

completely disrobed to the waist

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35
Q

All significant chest findings should be described as to how they relate to the

A

“grid” on the patient’s chest defined by the horizontal ribs and interspaces and the “imaginary” vertical lines. Ex: “expiratory wheezing is audible in the right third interspace, 2 cm medial to the mid-clavicular line”

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36
Q

Anterior Chest
Inspection
Examiner should stand

A

directly in front of patient but should have the ability to move from side to side to inspect the lateral and supraclavicular surfaces of the chest as well

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37
Q

Observe chest for size, shape, and symmetry

A

Note the approx. A-P diameter as it relates to the lateral diameter (A-P diameter: Lateral diameter should be 1:2)

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38
Q

Increased AP to lateral diameter is associated with

A

air-trapping conditions, esp. chronic bronchitis, emphysema, cystic fibrosis

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39
Q

Ask the patient to take a deep breath.

A

Note the degree and the symmetry of respiratory expansion. Note the ease with which a patient can expand the chest.

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40
Q

Observe whether there is any splinting of the chest wall from apparent pain

A

Note the posture required by the patient to facilitate a full inhalation. Note the use of accessory muscles when breathing

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41
Q

In thin patients note the costal angle and estimate the number of degrees (this may not be possible to observe in obese patients but can be estimated by palpation later)

A

Increased costal angle (Greater than 90 degrees) is associated with the air-trapping conditions.

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42
Q

Observe the position of the patient’s sternum relative to the anterior ribs

A

1.) If more anterior than the anterior ribs = pectus carinatum
2.) If more posterior than the anterior ribs = pectus excavatum
These are congenital conditions that may be associated with other congenital conditions

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43
Q

Pectus excavatum can be the cause of

A

decreased lung volume and a heart that is pushed more to the left with compromised ability to deliver adequate cardiac output. It is frequently seen in Marfan’s syndrome (aortic arch dissection and aortic valvular incompetence) and is associated with mitral valve prolapse

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44
Q

Pectus carinatum is also noted in

A

Marfan’s syndrome

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45
Q

Palpation should be done in

A

Layers

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46
Q

Palpation of the skin:

A

Begin by very lightly touching the patient’s skin and observing for the temperature, texture, turgor, sensitivity, and skin masses

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47
Q

This palpation of the skin should include

A

the anterior, lateral, and supraclavicular surfaces; the posterior chest will be examined later. The patient should be asked to breathe normally at this time.

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48
Q

Palpation of the muscles:

A

touch and palpate with greater pressure to examine the second layer of the chest wall, the muscles. Note the bulk, tone, symmetry, and sensitivity of each muscle. Inspect for any involuntary contractions or masses.

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49
Q

Palpation of the bones:

A

the third layer, the bones, requires knowledge of the normal bony structure of the chest wall.

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50
Q

When palpating bones, note

A

size, position, masses, sensitivity and stability. Observe for instability or bony crepitus.

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51
Q

Bones to include in palpation of the thoracic skeleton are the

A

clavicles, sternum, manubrium, anterior and lateral ribs and the costal cartilages

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52
Q

A quick assessment of the general rib stability and/or rib tenderness is accomplished by

A

compressing the chest in an anterior-posterior direction. This is performed by placing one hand on the patient’s sternum and the other hand on the patient’s spine and, by pushing the hands toward one another, any rib tenderness will be easily demonstrated as pain

53
Q

Lastly, palpate the

A

lungs.

54
Q

It is possible to feel, on the surface of the chest wall, evidence of the function of the lungs. This is done in 2 ways:

A
  1. ) Thoracic Expansion

2. ) Tactile Fremitus

55
Q

Thoracic Expansion

This maneuver is done to roughly measure the degree to which a patient can

A

expand the chest with a deep inspiration

56
Q

Thoracic Expansion
The examiner places the fingertips of both hands firmly on the lateral chest walls, as far to the patient’s sides as possible, while

A

still being able to bring the thumbs of both hands together just below the patient’s xiphoid bone

57
Q

Thoracic Expansion

With the thumbs only lightly touching the patient, ask the patient to

A

take as deep a breath as possible. Keeping the fingertips firmly in place, allow the thumbs to glide apart over the surface of the patient’s skin and note (measure in cm) how far apart the pt. can move the examiner’s thumbs with just the expansion of his lower chest

58
Q

Tactile Fremitus

This maneuver is done to assess the degree of

A

aeration of the lungs and the presence of any substance in the pleural spaces

59
Q

Tactile Fremitus

With the examiner firmly but lightly touching the skin of the chest, the pt. is asked to

A

recite words that have a strong vocal quality, such as “ninety-nine”

60
Q

Tactile Fremitus

By palpating while the patient repeats the words “99”, vibrations can be felt on

A

the surface of the chest wall.

61
Q

Tactile Fremitus

These vibrations are created by the pt.’s

A

vocal cords and transmitted bi-directionally; outward, which the examiner hears as speech and backward into the alveoli; which the examiner can feel as vibrations. Note the intensity and symmetry of the vibrations.

62
Q

Tactile Fremitus

The most sensitive parts of the hands with which to feel tactile fremitus are the

A

bases of the fingers or the ulnar surfaces

63
Q

Palpate for tactile fremitus by placing both hands simultaneously in

A

several symmetrical locations on the anterior, lateral, and supraclavicular surfaces of the chest; the posterior surface will be examined later.

64
Q

Decreased fremitus will be noted in any conditions in which

A

vocal cord vibrations are prevented from reaching the chest wall.

65
Q

Decreased fremitus will be noted in the following conditions:

A

asthma during an acute attack b/c of the bronchospasm of the upper airway occluding the air passages

66
Q

Decreased fremitus will be noted in the following conditions:

A

atelectasis b/c of the deflated alveoli and (usually) the occluding lesion in the bronchus causing the atelectasis

67
Q

Decreased fremitus will be noted in the following conditions:

A

Emphysema b/c of the deminished number of alveoli capable of vibrating

68
Q

Decreased fremitus will be noted in the following conditions:

A

Chronic obstructive bronchitis b/c of the occluding mucus plug in the major bronchi common in this condition

69
Q

Decreased fremitus will be noted in the following conditions:

A

Pleural effusion b/c of the interposition of free fluid b/t the vibrating alveoli and the chest wall

70
Q

Decreased fremitus will be noted in the following conditions:

A

Pneumothorax b/c of the interposition of free air b/t the vibrating alveoli and the chest wall

71
Q

NOTE: Fremitus may be ___ in a large pneumothorax

A

totally absent

72
Q

Increased fremitus is noted in those conditions in which the lung tissue is more

A

solid than usual (air in the alveoli somewhat dampen the intensity of vocal cord vibrations)

73
Q

Solid lung tissue (as seen in pneumonia and a large solid mass (lung tumor) that is still in contact with patent air passages will

A

vibrate with greater intensity than usual. This increased fremitus is most often noted in consolidated lobar pneumonia in which the bronchi are still patent

74
Q

Note: there is normal asymmetry to those vibrations over the

A

precordium because of the imposition of the heart between the lung tissue and the chest wall

75
Q

Note: Palpation for tactile fremitus on a female patient’s chest requires that the

A

breasts be “pushed aside” as far as possible. It is not possible to evaluate tactile fremitus through breast tissue

76
Q

Percussion is a technique employed by the examiner to create sounds with the hands that will

A

penetrate the chest cavity (and the lung) and then reverberate back to the examiner’s ears. It is used to evaluate the degree of aeration of underlying lung tissue

77
Q

Percussion: Ask the patient to sit

A

upright as straight as possible

78
Q

Percussion

Place on the long finger of the non-dominate hand firmly against the chest wall

A

not allowing any other part of the hand to come in contact. This finger is called the pleximeter

79
Q

Percussion

Flex the long finger of the dominant hands 90 degree at the PIP joint but keep the

A

DIP joint fully extended. This long finger is called the plexor.

80
Q

Percussion

By striking the DIP joint of the pleximeter with the tip of the plexor like a hammer, a

A

sound will be created that can penetrate several centimeter’s into the patients chest

81
Q

Percussion

Correct striking motion is with the

A

wrist only, (do not use forearm) and with a sharp, brief contact b/t the plexor and the pleximeter

82
Q

Percussion

Perform percussion in several symmetrical areas on the

A

anterior, lateral, and supraclavicular surfaces of the chest wall.

83
Q

Percussion

The reflected sound coming back to the examiner’s ears from normal, well-aerated lung has a tonal quality referred to as

A

resonance

84
Q

Percussion

The percussion notes heard in symmetrical areas should be equal in

A

loudness (intensity) and tonal quality but there is a normal dull percussion note heard over the precordium, again bc of the fluid filled heart

85
Q

A dull percussion note can be heard over lung tissue that is comparatively deflated when compared to normal lung

A

These conditions include atelectasis, lobar pneumonia (because the alveoli are filled with fluid), or over a large lung tumor or abscess located close to the surface of the lung.

86
Q

A dull (or flat) percussion note will also be noted over an area of pleural effusion because of

A

the large area of fluid (and the absence of air) between the lung tissue and the chest wall.

87
Q

A hyperresonant percussion note will be noted over lung tissue in which the alveoli are

A

comparatively overfilled with air compared to normal lung tissue. These include emphysema, asthma (during the acute attack), and chronic obstructive lung disease.

88
Q

A hyperresonant note will also be noted over an area of pneumothorax because

A

of the large pocket of air between the lung and the chest wall

89
Q

Auscultation is typically performed with the diaphragm of the stethoscope because

A

the diaphragm is designed to hear high-pitched sounds and most respiratory sounds are high- pitched.

90
Q

Auscultation

The examiner should stand at the side of the patient to place an arm across the patient’s upper back

A

This is to allow the examiner to be able to prevent a patient from falling if they become dizzy from deep breathing

91
Q

Begin auscultating the chest in the supraclavicular areas

A

moving the stethoscope from side to side to symmetrical areas

92
Q

The examiner should ask the patient to take slow, deep breaths in and out through the mouth (examiner may have to demonstrate this) and listen for

A

a minimum of two full breaths at each area.

93
Q

Continue these steps, moving in a stair-step fashion, auscultating several areas in the

A

anterior and lateral surfaces and comparing breath sounds in symmetrical areas

94
Q

In evaluating breath sounds, characteristics to note include their

A

intensity, their pitch, and the durations of their inspiratory and expiratory phases

95
Q

Discontinuous adventitious sounds

A

These are sounds called crackles or rales and are further classified as fine crackles and coarse crackles

96
Q

Discontinuous adventitious sounds

A

They are intermittent, can range from high (fine crackles) to low pitch (coarse crackles), and are heard during inspiration only. They do not clear with coughing.

97
Q

Continuous adventitious sounds

A

These are sounds called wheezes or rhonchi. They are continuous, can be heard during either inspiration or expiration or both, can be high-pitched (wheezes) or low-pitched (rhonchi), and may clear with coughing.

98
Q

If any abnormal lung finding is detected on inspection, palpation, percussion, or especially auscultation

A

one further auscultatory maneuver should be done.

99
Q

The examiner should evaluate the type of transmitted voice sounds that

A

can be heard through the abnormal areas.

100
Q

While the patient is saying “ninety-nine,” the examiner auscultates over the suspect area.

A

These words are not well transmitted through normal well-aerated lung tissue and are muffled and indistinct

101
Q

If these words are heard well and distinctly as “ninety-nine”

A

the patient is said to have bronchophony in this area. This usually means that the lung underlying this area is probably consolidated as occurs in lobar pneumonia

102
Q

An additional test done to confirm this finding is to ask the patient to say the letter “E” repeatedly

A

Normally, this sounds to the examiner as the letter “E” but through consolidated lungs tissues it is heard distinctly as “A”. This finding is referred to as egophony

103
Q

A variation to the bronchophony test is to ask the patient to whisper the words “ninety-nine”;

A

if they are heard loudly and distinctly, this is the abnormal sign referred to as whispered pectoriloquy.

104
Q

POSTERIOR CHEST INSPECTION

The examiner should stand directly

A

behind the patient and the patient should be sitting up straight. Observe the size, shape and symmetry of the thorax from this direction.

105
Q

Posterior Chest
Palpation
Palpate the skin:

A

Lightly touch the skin, applying only enough pressure to note skin temperature, texture,
turgor, and the presence of any subcutaneous masses.

106
Q

Posterior Chest
Palpation
Palpate the muscles

A

Palpate a little deeper with enough finger pressure to note muscular tone, bulk, tenderness, or masses. Understand the anatomy of the named muscles of the back.

107
Q

Posterior Chest
Palpation
Palpate the bones

A

Specifically palpate the posterior ribs, the scapulae, and the thoracic spine noting tenderness, deformity, masses, or bony crepitus.

108
Q

Posterior Chest
Palpation
Palpation of the “lungs” on the posterior chest is done to detect the degree of

A

tactile fremitus. This is best accomplished by asking the patient to hunch forward, folding his arms across the front of the chest. This allows the scapulae to move laterally, exposing more of the lung to be “exposed” for examination

109
Q

Posterior Chest
Palpation
Palpate the lungs: Using the same techniques that were used on the anterior and lateral chest, ask the patient to again repeat the words

A

“ninety-nine”, moving both hands simultaneously to several symmetric locations and comparing the degree of tactile fremitus. There are no normal asymmetries of tactile fremitus on the posterior chest.

110
Q

Posterior Chest
Percussion
Percussion of the lung fields for the intensity and quality of the reflected sound is done

A

in the same way as is described for the anterior-lateral chest.

111
Q

Posterior Chest
Percussion
The patient should again be in the hunched over position with

A

the arms folded in front to expose as much of the lung to the percussion technique as possible

112
Q

Posterior Chest
Percussion
A second use of percussion is employed on the back;

A

it can be used to measure the amount of diaphragmatic excursion

113
Q

Posterior Chest
Percussion
Diaphragmatic excursion is the number of centimeters that a patient can

A

lower the diaphragm with a full inspiration

114
Q

Posterior Chest
Percussion
The position of the diaphragm at rest can be detected by

A

percussion on the posterior chest wall

115
Q

Posterior Chest
Percussion
By beginning the percussion in an area of normally resonant lung above the diaphragm and

A

percussing slowly downward in 1cm increments until the area of dullness is detected, the examiner will observe that the sound of the percussion note will change to a dull percussion note over the non-aerated tissues below the diaphragm

116
Q

The place on the posterior chest wall where the percussion note changes from resonance to dullness is the position of the diaphragm at rest.

A

This spot can be marked with a skin marking pencil

117
Q

Posterior Chest
Percussion
Now ask the patient to take a deep breath and hold it.

A

Percussing again at the location of the diaphragm at rest will reveal that the area that was dull is now resonant

118
Q

Posterior Chest
Percussion
This is because by taking a deep breath, the patient has depressed his diaphragm,

A

more lung has inflated with air and now occupies more of the chest cavity.

119
Q

Posterior Chest
Percussion
Beginning at the pencil mark, resume percussion in 1 cm increments downward until a new point is detected between resonance above and dullness below

A

This is the new position of the diaphragm and its location can be marked with a skin marking pencil

120
Q

Posterior Chest
Percussion
By measuring the distance between these two pencil marks, the number of centimeters of diaphragmatic excursion can be noted.

A

[Note: A normal healthy adult with good lungs and lung function should be able to lower the position of the diaphragm at least 4 centimeters with a deep inspiratory effort.]

121
Q

Posterior Chest
Percussion
Common conditions resulting in decreased diaphragmatic excursions are

A

asthma (during the acute attack), chronic obstruction lung disease, emphysema, phrenic nerve paralysis, obesity, chest wall stiffness, ascites, abdominal pain, subphrenic abscess.

122
Q

Posterior Chest
Auscultation
Auscultation of the posterior lung fields is done in the same way that is described for the anterior chest

A

After about 10-12 deep breaths, allow the patient to rest by breathing normally for 1-2 minutes

123
Q

Posterior Chest
Auscultation
The examiner should stand at

A

the side of the patient with an arm placed across the patient’s upper anterior chest. This will prevent the patient from falling forward while the examiner is auscultating

124
Q

Locations on the Chest

Supraclavicular

A

Above the clavicles

125
Q

Locations on the chest

Infraclavicular

A

Below the clavicles

126
Q

Locations on the chest

Interscapular

A

Between the scapulae

127
Q

Locations on the chest

Infrascapular

A

Below the scapula

128
Q

Locations on the chest

Bases of the Lungs

A

The lowermost portion

Exam 2 (4 decks)

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