Thorax Flashcards
congestive heart failure (trachea, tactile fremitus, percussion, breath sounds, adventitious sounds)
- Trachea - midline
- Tactile Fremitus - decreased
- Percussion – resonant Breath sounds – vesicular
- Adventitious sounds – late inspiratory crackles in the dependent portions of lungs; possibly wheezes.
Notes: engorged capillaries where air exchange is occurring in the lungs
Makes dependent airways deflate.
Pneumothorax (trachea, tactile fremitus, percussion, breath sounds, adventitious sounds)
Trachea – shifted toward opposite side if much air
Tactile Fremitus – decreased to absent over pleural air
Percussion –hyperresonant to tympanic over pleural air
Breath sounds – decreased to absent over pleural air
Adventitious sounds – none, except a possible pleural rub
Pleural Effusion (trachea, tactile fremitus, percussion, breath sounds, adventitious sounds)
Trachea – shifted toward opposite side in large effusion
Tactile Fremitus – decreased to absent
Percussion – dull to flat over fluid
Breath sounds – decreased to absent, but bronchial sounds may be heard near top of large effusion
Adventitious sounds – none, except a possible rub
Note: blocks the transmission of sound and also collapses the alveoli
Asthma (trachea, tactile fremitus, percussion, breath sounds, adventitious sounds)
Trachea - midline
Tactile Fremitus - decreased
Percussion – resonant to hyperresonant
Breath sounds – often obscured by wheezes
Adventitious sounds – wheezes, possibly crackles
Notes:
- constriction in the bronchi, also get edema
- Lungs will overinflate when you have an asthma attack
- Widespread narrowing of the trachobronchial tree as well as bronchospasms
Emphysema (trachea, tactile fremitus, percussion, breath sounds, adventitious sounds)
Trachea - midline Tactile Fremitus - decreased Percussion – hyperresonant Breath sounds – decreased to absent Adventitious sounds –none or scattered coarse crackles in early inspiration and perhaps expiration; or wheezes and rhonchi associated with chronic bronchitis
Note:
- alveoli become distended and patient cannot get the air out
- Hyperresonant percussions – not quite tympanic, like you would hear over the stomach, but there is more air trapped in the lung
Bronchitis (trachea, tactile fremitus, percussion, breath sounds, adventitious sounds)
Trachea - midline
Tactile Fremitus - normal
Percussion – resonant
Breath sounds – vesicular except perhaps over large bronchi or trachea
Adventitious sounds –none or scattered coarse crackles in early inspiration and perhaps expiration; or wheezes and rhonchi
Notes:
- inflammation in the bronchioles
- Copious secretions of mucus
- You can get some airway obstruction
- Productive cough
Consolidation-Pneumonia (trachea, tactile fremitus, percussion, breath sounds, adventitious sounds)
Trachea - midline
Tactile Fremitus – increased over involved area with bronchophony, egophony, whispered pectoriloquy
Percussion – dull over airless area
Breath sounds – bronchial over involved area
Adventitious sounds – late inspiratory crackles over involved area
Atelectasis- Lobar Obstruction (trachea, tactile fremitus, percussion, breath sounds, adventitious sounds)
Trachea: may be shifted towards involved side
Tactile Fremitus: usually absent
Percussion: dull over airless area
Breath sounds: usually absent when bronchial plug.
Adventitious sounds: none
normal lung (trachea, tactile fremitus, percussion, breath sounds, adventitious sounds)
- Trachea: midline
- Tactile Fremitus: normal
- Percussion: resonant
- Breath sounds: vesicular except perhaps over large bronchi or trachea
- Adventitious sounds: none
developmental considerations for older adults
- Chest shows an increased anteroposterior diameter and kyphosis. Person compensates by holding the head extended and tilted back.
- Chest expansion may be somewhat decreased.
- Older person may fatigue easily. Allow brief rest periods with quiet breathing.
developmental considerations for infants and children
- Let the parent hold supported against the chest or shoulder. Offer the stethoscope to children.
- Infants have a rounded thorax until age 6.
- Infants breath through the nose rather than mouth until age 3 months.
- The diaphragm is the major respiratory muscle.
- Infant Rate 30-40
- Auscultation normally is bronchovesicular breath sounds in the peripheral lung field up to age 6.
Anterior Thoracic Cage
- Suprasternal notch
- Sternum (Manubrium, Body, Xiphoid process)
- Manubriosternal angle (“Angle of Louis”)
- Costal angle
Posterior Thoracic Cage
- Vertebra Prominens (C7)
- Spinous Processes
- The inferior border of the scapula is usually at the 7th or 8th rib.
- 12th Rib - palpate midway between spine and side to find the location free tip
what are the 3 lateral reference lines?
- Anterior Axillary
- Posterior Axillary
- Midaxillary lines
subjective data - health history questions
Cough Sputum Dyspnea Orthopnea Chest pain with breathing Hemoptysis Past history of respiratory infections Smoking history Environmental exposure
7 key points of thorax physical assessment
- Inspection
- Respiratory excursion
- Palpate for tactile fremitus
- Percuss for symmetry
- Diaphragmatic excursion
- Auscultate posterior chest
- Repeat inspection, palpation, percussion and auscultation on anterior chest
configurations of the thorax (5 abnormalities)
- barrel chest
- Pectus Excavatum
- Pectus Carinatum
- Scoliosis
- Kyphosis
Anteroposterior : Transverse diameter
Anterior posterior/transverse 1:2
Costal angle should be
facial expressions
- pink puffer: pink complexion, shortness of breath, sitting in tripod position
- blue bloater: cyanosis, right-sided heart failure, this is also caused by COPD, whether that’s chronic bronchitis or emphysema
respiration patterns (normal vs. 5 abnormalities)
- Tachypnea
- Bradypnea
- Kussmaul
- Cheyne-Stokes
- Biot’s
Biot’s
- Less regular than Cheyne-Stokes; periods of increased depth and flow followed by a period of apnea
- Occurs from brain trauma, heat stroke, abscess in the brain
Cheyne-Stokes
- respirations wax and wane in an irregular pattern – shallow to deep, then period of 20 seconds with no breathing at all, and so on
- occurs with increase ICP, renal failure
Kussmaul
- Tachypnea (rapid) but a much deeper breathing than regular tachypnea
- occurs with diabetics
Bradypnea
- less than 10 respirations per minute
- can occur as a result of drugs (morphine), increased intracranial pressure
Tachypnea
- increased respirations (24, over 20)
- occurs after exercise, with fever, pneumonia, emotion
Palpate for symmetric expansion
- Place both hands on posterior chest with thumbs at T9 or T10.
- Pinch up a small fold of skin.
- Ask person to take a deep breath.
Your thumbs should move apart symmetrically
Palpate for tactile fremitus
- Use palmar base of finger or ulnar edge, touch chest while patient say ninety-nine
- Start over apices and palpate from side to side or compare sides
- Sound is conducted better through a dense or solid structure than porous so anything that increase density of lung will increase fremitus
abnormal tactile fremitus: increased vs. decreased
- Increased tactile fremitus: pneumonia, pus, etc.
- Decreased tactile fremitus: anything that obstructs transmission of sound from the larynx through the bronchi out to the chest wall, when lung is collapsed
3 kinds of Transmitted Voice Sounds
Bronchophony
- “99” clear rather than muffled
Egophony
- “E” to “A” changes
Whispered Pectoriloquy
- louder clear whispered “99“ rather than faint or absent sound
dry cough
could be early sign of congestive heart failure
hacking cough
pneumonia
morning cough
smoker’s cough
allergies or irritants
usually in the afternoon
White or clear, Mucoid or stringy sputum
cold, could be bronchitis or viral infection
Yellow or green sputum
bacterial infection
Rust-colored sputum
TB or pneumococcal pneumonia
Frothy and pink sputum
pulmonary edema
Dyspnea
- difficulty breathing
- Normally can do 10-15 words before we’re short of breath
- Ask questions about activities, number of stairs
orthopnea
- sensation of breathlessness when lying down (recumbent position)
- relieved by sitting or standing, using pillows to prop up
chest pain with breathing
Burning, stabbing sensation could be inflammation of the pleura
Hemoptysis
- coughing up blood
- Sometimes with pneumonia, but mostly with TB or a pulmonary embolism, heart failure
- Always distinguish between coughing up blood or vomiting up blood
Kyphosis
i. Osteporosis, breakdown in the spinal column
ii. Happens in older adults
iii. Doesn’t usually affect their ability to breathe, but it will be difficult for you to hear their lungs/heart
Scoliosis
any abnormal, sideways curvature of the spine
Pectus Carinatum
breast bone is kind of protruding from the chest wall
Pectus Excavatum
breastbone is kind of depressed, it depends on how depressed it is if it becomes a problem
when would the thumbs not move symmetrically while palpating for symmetric expansion?
Collapsed lung, partial lung collapse, really sick with pneumonia
percussions of the posterior chest
i. Percussion is tapping with a very relaxed wrist, tapping middle finger
ii. Trying to listen to the underlying structures
iii. Dolmus: when the air-filled lung is replaced with a dense material like with pneumonia or a pleural effusion (?)
iv. It takes quite a bit of obstruction to make a dull sound when percussing
v. Flat sound will happen over scapula
normal diaphragmatic excursion
Space is about 3-5cm
3 kinds of breath sounds that are considered normal
- vesicular
- bronchovesicular
- bronchial or tubular
What are the 3 kinds of abnormal/adventitious breath sounds
Crackles (Rales)
- Fine
- Coarse – sound like Velcro being pulled apart
Wheezes
- Sonorous (rhonchi)
- Sibilant (associated with asthma, more musical sounding)
Pleural rub
- Pleural friction rub – quite painful, sounds like leather rubbing together
vesicular breath sounds
- when inspiration is about 2.5x length of expiration
- most common
- soft and low pitched
bronchovesicular breath sounds
equal inspiration and expiration, 1:1
bronchial or tubular breath sounds
inspiration is shorter than expiration by half
thoracic cage
bony structure in a conical shape, narrower at the top and wider at the bases
defined by the sternum, 12 pairs of ribs, and 12 thoracic vertebrae
floor of the cage is the diaphragm
diaphragm
musculotendon septum that separates the thoracic cavity from the abdomen
Where do ribs 1-7 attach?
to the sternum directly via the costal cartilage
Where do ribs 8, 9, 10 attach?
to the costal cartilage above
Why are ribs 11 and 12 called floating ribs?
because they have free, palpable tips
costochondral junction
where the ribs join into the cartilage and then attach to the sternum
suprasternal notch
hollow, U-shaped depression in between the clavicles
What are the 3 parts of the sternum?
- manubrium
- body
- xiphoid process
What is the angle of Louis?
articulation of the manubrium and the body of the sternum - is continuous with the 2nd rib - good place to start counting ribs
marks the site of the tracheal bifurcation into the right and left main stem bronchi
corresponds with the upper border of the atria of the heart
also is the same place as the 4th thoracic vertebra of the back
What is the costal angle, and what is the normal degree?
right and left costal margins form an angle where they meet at the xiphoid process
usually 90 degrees or less is normal
emphysema widens the angle so that chest becomes barrel-shaped
Where is the scapula located?
symmetrically - lower tip between 7th and 8th rib
What are the 5 reference lines for the lungs?
- midsternal line
- the midclavicular line (bisects the center of each clavicle)
- anterior axillary line (extends down from anterior axillary fold)
- posterior axillary line (from the posterior axillary fold)
- midaxillary line - runs from the apex of the axilla and lies between and parallel to the two other lines that we’re talking about
mediastinum
middle section of the thoracic cavity which contains esophagus, trachea, heart, great vessels (inferior and superior vena cava, aorta, pulmonary veins and arteries)
Where are the apex and base of lung from the anterior view?
apex of the lung is about 3 or 4 cm above the inner 3rd of the clavicle, base rests on the diaphragm around the 6th rib on the midclavicular line
Where are the apex and base of lung from the posterior view?
apex is at C7, base is at T10
The right middle lobe can only be listened to in one way: how?
from the front of the patient’s body
Size differences between right and left lungs
right lung is shorter than left lung because of liver
left lung is narrower than left lung because of heart
anterior chest contains mostly ___ with very little ____
upper and middle lobe; lower lobe
posterior chest contains almost all
lower lobe
How many lobes do each of the lungs have?
Right: 3, Left: 2
How do you listen to the lungs of a patient who is lying in bed on their back, and why?
you MUST listen to lungs from behind b/c most secretions going into lower lobe
visceral pleura lines the
outside of the lungs
parotid pleura lines the
inside of the chest wall and the diaphragm
pleural effusion
compromises ability for lung to expand
Location and size of the trachea
lies anterior to the esophagus and is 10-11 cm long in the adult
right mainstem bronchus is ____ than the left
a bit shorter, wider, and more vertical
Function of the trachea and bronchi
transport gases between the environment
they constitute the dead space (space that’s filled with air but not available for gaseous exchange -about 150 mL in the adult)
bronchi are lined with (2 things)
goblet cells that secrete mucus
cilia that moves mucous
Where does gas exchange occur?
across the respiratory membrane in the alveolar duct and in the alveoli – surface area is as large as a tennis court
4 main functions of respiration
- to supply oxygen to the body for energy production
- remove carbon dioxide as a waste product
- maintain homeostasis (acid/base balance)
- maintain heat exchange (less important)
body tissues are bathed by blood that has a very narrow acceptable range of pH, which is
7.35-7.45
high CO2 helps to stimulate breathing much more than
low C02
during inspiration, the AP diameter
increases
expiration is
primarily passive
egophony, bronchophony and whispered pectoriloquy are all transmitted voice sounds to determine if
there is a density in the lungs such as consolidation, which is pneumonia
where should you hear resonance?
over the lungs
if you hear dullness over the lungs, what does it mean?
pneumonia or pleural effusion
what is hyperresonance, and what kind of patient do you hear that in?
COPD, emphysema
Resonance increased above the normal, and often of lower pitch, on percussion of an area of the body; occurs in the chest as a result of overinflation of the lung as in emphysema or pneumothorax and in the abdomen over distended bowel
what is venous insufficiency?
a condition in which the veins have problems sending blood from the legs back to the heart
causes: History of deep vein thrombosis in the legs, Obesity, Pregnancy, Sitting or standing for a long periods
what is arterial insufficiency?
patients are not getting enough oxygenated blood to their extremities
usually the legs b/c they are most dependent
nails get thicker, hair, skin feels cool
What happens in congestive heart failure?
the capillaries that are coming from inside the heart are very dilated, which can leads to fluid overload, pulmonary edema
pneumothorax can come from
emphysema, trauma (leak in chest wall)
what is pleural effusion?
A buildup of fluid between the tissues that line the lungs and the chest.
difference between bronchitis and asthma
bronchitis: bronchial inflammation, lots of secretions
asthma: in addition to the copious secretions and dilation of bronchi, they get bronchal spasms
ipsilateral means
same side
contralateral means
opposite sides
where to look for breast cancer in men and women?
men: under the nipple
women: tail of spence
how does lymphatic drainage work?
starts as a siphoning in the interstitial spaces, and then everything is going upstream or downstream towards the heart
if someone has a cut on their finger, they might have inflammation in the
epitrochlear or central axillary lymph nodes
if a patient has mastitis of the breast, they would have inflammation in
all of the lymph nodes
Fine crackles (rales) are often a sign of what 3 diseases?
- Restrictive disease
- Pneumonia
- CHF
Coarse crackles often accompany what 3 diseases?
- Pulmonary edema
- Pneumonia
- Atelectasis
Pleural friction rub is a sign of
Pleuritis
Wheeze (sibilant) is a sign of what 2 diseases?
- Asthma
2. Chronic emphysema
Rhonchi (sonorous wheezes) are a sign of what two diseases?
Bronchitis
Single bronchus obstruction
Stridor is present with what 3 diseases?
- Croup
- Acute epiglottitis
- Foreign body inhalation
