Thorax and Lung Exam

Question 1

Chest Dimensions

(2 descriptors, method of eval)

Answer 1

Descriptors:

1. Vertical axis
2. Chest circumference

Eval:

• Count ribs and interspaces
• Use sternal angle as landmark

Question 2

Vertical Lines of the Chest

(3 ant, 3 lat, 2 post)

Answer 2

**Anterior Lines **- midsternal, midclavicular, anterior axilary

Lateral Lines - anterior axillary, midaxillary, posterior axillary

Posterior Lines - vertebral, scapular

Question 3

Gross Lung Structure

Answer 3

• Each lung is divided roughly in half by an oblique (major) fissure
• The right lung is further divided by the horizontal (minor) fissure
• These fissures divide the lungs into lobes
  
  • The right lung is divided into upper, middle, and lower lobes
  • The left lung is divided into upper and lower lobes

Question 4

Landmark for Trachial Bifurcation

Answer 4

Posterior T4 spinous processes

Question 5

Lung Pleurae

Answer 5

The pleurae are serous membranes that cover the outer surface of each lung (visceral pleura), and also the inner rib cage and upper surface of the diaphragm (parietal pleura)

Question 6

Health History Questions, CC: CP

(6 considerations/questions)

Answer 6

1. Initial questions should be as broad as possible, such as, “Do you have any discomfort or unpleasant feelings in your chest?”
2. Ask the patient to point to the location of the pain
3. Attempt to elicit all attributes of the patient’s symptom
4. Aside from lung conditions, chest pain may arise from cardiac, vascular, gastrointestinal, musculoskeletal, or skin pathology; it is also commonly associated with anxiety
5. Lung tissue itself has no pain fibers; pain in lung conditions usually arises from inflammation of the adjacent parietal pleura
6. Other surrounding structures may also irritate the parietal pleura, causing pain

Question 7

Health History, CC: Dyspnea

(define dyspnea, 2 history questions)

Answer 7

**Def: **Dyspnea is a nonpainful but uncomfortable awareness of breathing that is inappropriate to the level of exertion

1. Begin assessment with a broad question, such as, “Have you had any difficulty breathing?”
2. Determine the severity of dyspnea based on the patient’s daily activities

Question 8

Define Wheezing

Answer 8

Wheezes are musical respiratory sounds that may be audible to the patient and to others

Question 9

Define Cough

Answer 9

Cough is typically a reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi; it may sometimes be cardiovascular in origin

Question 10

Health History, CC: Cough

(4 questions)

Answer 10

1. Ask whether the cough is dry or produces sputum, or phlegm
2. Ask the patient to describe the volume of any sputum and its color, odor, and consistency
3. If described as “bloody,”
   
   • Ask the patient to describe the volume of blood produced as well as other sputum attributes
   • Try to confirm the source of the bleeding by history and examination before using the term “hemoptysis”; blood may also originate from the mouth, pharynx, or gastrointestinal tract

Question 11

Hemoptysis

Answer 11

Hemoptysis is the coughing up of blood from the lungs; it may vary from blood-streaked phlegm to frank blood

Question 12

Health History, Tobacco Use

Answer 12

Smoking is the leading cause of preventable death in the United States

Remember the five “A”s

Ask about smoking at each visit

Advise patients regularly to stop smoking using a clear, personalized message

Assess patient readiness to quit

Assist patients to set stop dates and provide educational materials for self-help

Arrange for follow-up visits to monitor and
support patient progress

Question 13

General Thorax/Lung Exam Techniques

(3)

Answer 13

1. Examine the posterior thorax and lungs while the patient is sitting
2. Compare one side of the thorax and lungs with the other, so the patient serves as his or her own control
3. Proceed in an orderly fashion: inspect, palpate, percussion, and auscultate

Question 14

Signs of Respiratory Distress

(6)

Answer 14

1. General difficulty breathing (nasal flaring, stridor, pursed-lip breathing)
2. Use of accessory muscles
3. Orthopnea
4. Tripoding – sitting upright and leaning forward on outstretched arms
5. Paradoxical Breathing – inward movement of abdomen on inspiration
6. Use of oxygen/respiratory equipment

Question 15

Signs/Implications of Cyanosis

(3)

Answer 15

1. Signs of peripheral cyanosis include coolness and bluish color or extremities
2. Sign of central cyanosis include bluish mucous membranes
3. Central cyanosis occurs when oxygen saturation falls below 85%

Question 16

Respiratory Rate and Pattern

(normal, 5 abnormal)

Answer 16

Normal adults - 12-16 breaths/min

Abnormal adults -

1. Apnea: a period without breathing
2. Bradypnea: abnormally slow rate of respiration (< 12)
3. Cheyne-Stokes Breathing: periods of deep breathing alternating with periods of apnea
4. Hyperpnea (Kussmaul’s breathing): increased depth and rate of breathing
5. Tachypnea: abnormally fast rate of respiration (> 16)

Question 17

Chest Configuration

(normal, 4 abnormal)

Answer 17

Normal - AP diameter < lateral diameter

Abnormal -

1. Barrel chest: AP diameter = lateral diameter
2. Pectus Excavatum (funnel chest): a depression of the sternum; associated with mitral valve disease
3. Pectus Carinatum (pigeon chest): an anterior protrusion of the sternum
4. Kyphosis: abnormal AP curvature of spine

Question 18

Chest Palpation

(list and describe 3 methods)

Answer 18

1. Chest Wall Tenderness
   
   • Palpate all areas of chest for tenderness and deformities
2. Chest Expansion
   
   • Place hands flat on back with thumbs parallel to the midline at the level of the 10th rib and fingers gripping the flanks
   • Ask patient to exhale completely and then inhale deeply; look for symmetry in outward movement of hands
   • Asymmetrical with pleural effusion, lobar pneumonia, pulmonary fibrosis, bronchial obstruction, pleuritic pain with splinting, pneumothorax
3. Tactile Fremitus
   
   • Place ulnar side of the hand against chest wall and ask patient to say “ninety-nine” or “boy-oh-boy”
   • The hand must be moved from side-to-side to compare left to right sides and from the top downward
   • Increased = consolidation (pneumonia)
   • Decreased Unilateral = atelectasis, bronchial obstruction, pleural effusion, pneumonthorax
   • Decreased Bilateral = chest wall thickening (muscle, fat), COPD, bilateral pleural effusion

Question 19

Thorax Percussion

(procedure, 5 potential results)

Answer 19

Procedure

1. Percussion is performed side to side to assess for asymmetry
2. Strike using the tip of your tapping finger

Results

• Normal = resonant
• Dull = lobar pneumonia, hemothorax, atelectasis, tumor
• Hyperresonant = emphysema, asthma, pneumothorax
• Flatness = large pleural effusion
• Tympany = large pneumothorax

Question 20

Diaphragmatic Excursion

(define, 4 step procedure, normal result)

Answer 20

Diaphragmatic Excursion: measuring of diaphragm movement from full inspiration to full expiration.

Procedure:

1. Patient takes deep breath in and holds
2. Provider percusses level of diaphragm, when it goes from resonant to dull, make mental note.
3. Patient exhales completely and holds
4. Provider percusses level of diaphragm, when it goes from resonant to dull, make mental note.

Normal diaphragmatic excursion is 4-5 cm

Question 21

Lung Ascultation

(significance, 3 step proedure)

Answer 21

Significance:

1. Auscultation of the lungs is the most important examination technique for assessing air flow through the tracheobronchial tree
2. Together with percussion, it also helps to assess the condition of the surrounding lungs and pleural space

Procedure:

1. Listen to the breath sounds with the diaphragm of a stethoscope after instructing the patient to breathe deeply through an open mouth
2. Use the pattern suggested for percussion, moving from one side to the other and comparing symmetric areas of the lungs
3. Listen to at least one full breath in each location

Question 22

Normal Posterior Lung Sounds

(3)

Answer 22

1. Vesicular: soft and low pitched; usually heard over most of both lungs
2. Bronchial: louder and higher in pitch; usually heard over the manubrium
3. Bronchovesicular: intermediate intensity and pitch; usually heard over the 1st and 2nd interspaces and between scapula posterior

Question 23

Anterior Chest Auscultation

Answer 23

1. As for examination of the posterior chest, proceed in an orderly fashion: inspect, palpate, percuss, and auscultate
2. With percussion, the heart normally produces an area of dullness to the left of the sternum from the 3rd to 5th rib interspaces
3. Supraclavicular retraction is often present

Question 24

Adventitious Lung Sounds

(2 categories, 2/3 sounds)

Answer 24

Discontinuous sounds

1. Crackles - Intermittent, non-musical, and brief
2. Fine Crackles - Soft, high-pitched and very brief
3. Heard with CHF - Course Crackles
4. Louder, lower-pitched, and longer

Continuous sounds

1. Wheezes - Musical, high-pitched (indicative of asthma)
2. Rhonchi - Lower-pitch, snoring (indiccative of secretion in large airways)

Question 25

Transmitted Voice Sound Tests

(list 3)

Answer 25

1. Bronchophony
2. Egophony
3. Whispered Pectoriloquy

Question 26

Bronchophony

(procedure, negative/positive results)

Answer 26

Procedure: ask the patient to say “99” as you place your stethescope in typical configurations

Results:
◦Normal/Negative: the sound transmitted through the chest wall are muffled and indistinct.
◦Abnormal/Positive: the sound transmitted are louder and clearer.
–This can indicated an airless lung – lobar pneumonia

Question 27

Egophony

(procedure, negative/positive results)

Answer 27

Procedure: ask the patient to say “ee” while listening to lungs in the typical pattern

Results:
◦Normal/Negative: you will normally hear a muffled long E sound.
◦Abnormal/Positive: you will hear the “ee” as “ay” known as an E-to-A change.
–This can indicated an airless lung – lobar pneumonia

Question 28

Whispered Pectoriloquy

(define, normal/abmoral reuslts)

Answer 28

Procedure: ask the patient to whisper “99” or “1-2-3” while auscultating in the typical lung formation

Results:
–Normal/Negative: whispered voice is normally heard faintly and indistinctly, if at all
–Abnormal/Positive: the whispered voice is louder and clearer.
–This can indicated an airless lung – lobar pneumonia