Thorax and Lungs Flashcards
Sternal angle
Angle of Louis
where the manubrium and sternum touch.
It is continuous with the 2nd rib.
Anterior reference lines
Anterior axillary
Midclavicular- “nipple line”. Midclavical to the umbilicus.
Midsternal
Posterior reference lines
vertebral
scapular
posterior axillary
Lateral reference lines
Midaxillary
anterior axillary
posterior axillary
Apex of lung
Highest point, lung tissue is 3 to 4 cm above the inner third of the clavicle.
Base of lung
Lower border, rests on the diaphragm at about the 6th rib in the midclavicular line.
Cough
Do you have a cough? When did it start? Acute coughs lasts less than 2-3 weeks. Chronic cough lasts over 2 months Do you cough up any phlegm or sputum? If yes what color and how much?
Hemoptysis
Blood in sputum.
Dyspnea
Short of breath or difficulty breathing
Orthopnea
Difficulty breathing while laying down.
Paroxysmal nocturnal dyspnea (PND)
awakening from sleep with shortness of breath and needing to be upright to achieve comfort.
Chest pain with breathing
pain in thoracic cavity can be soreness from coughing or inflammation of the pleura overlying pneumonia.
Have patient describe the pain.
Order of exam
Inspection Palpation Percussion Ausculation Do in order. Do not start with lateral.
Thoracic cage
- shape and configuration
- position patient takes to breathe. COPD patients often lean forward with arms braced against knees, chair or bed when breathing.
- Skin color and condition- skin should be consistent with person’s genetic background.
AP Diameter
- Anterior-Posterior (front to back) TO Transverse (side to side)
- Normal ratio 1:2. 2 hands on the back and 1 hand laterally.
- Barrell Chested 1:1
- Long term lung issue people use accessory muscles to breathe causing change in the shape. Compensatory Hypertropy.
Palpation- posterior chest
Symmetric chest expansion
- Looking for symmetry.
- Place both hands on back with thumbs touching and have them take a deep breath. Watching for symmetrical rise and fall.
- Also checking for lumps, bumps, and anything abnormal.
Tachypnea
- rapid and shallow
- > 24 breaths per minute
Bradypnea
- Slow breathing
- <10 breaths per minute
Tactile (or vocal) fremitus
- Vibration when the person says 99.
- Vibration all the way through the lung.
- Looking for symmetrical vibrations bilaterally
- Loudest at apex
- Asymmetric findings suggest dysfunction
- Use palm
Decreased fremitus
Occurs with obstructed bronchus, pleural effusion, pneumothorax or emphysema. Any barrier that comes between the sound and your palpating hand decreases fremitus.
Increased fremitus
Occurs with compression or consolidation of lung tissue. (e.g. Lobar pneumonia)
-Gross changes increase fremitus.
Percussion of thorax
Percussion sounds
- Resonance- normal sound in lungs. Low pitched, clear, hollow. May be duller in an athlete with more muscle mass or an obese person.
- Hyperresonance- abnormal for adults. Happens with infection. Lower pitched, booming sound when too much air is present as in pneumothorax or emphysema.
Hyperventilation
Increase in rate and depth. Inspiration=Expiration.
Hypoventilation
Irregular shallow caused by an overdose of narcotics or anesthetics.
Sigh
Normal breathing pattern and are purposeful to expand alveoli. Emotional response.
Normal breathing
Rate is 10-20 breaths per minute. I=E.
Cheyne-Stokes respiration
Respirations wax and wane in a regular pattern, increasing in rate and depth and then decreasing.
-Early sign of death.
Biot’s respirations
- Similar to cheyne-stokes but the pattern is irregular. A series of normal respirations followed by apnea. cycle length is variable.
- Seen with head trauma, brain abscess, heat stroke, spinal meningitis, and encephalitis.
Chronic obstructive breathing
Normal inspiration and prolonged expiration to overcome increased airway resistance.
Auscultation interference
- Stethoscope tubing bumping together
- patient shivering
- patient’s hairy chest rustling
Vesicular sounds
- Normal
- Sounds like wind rustling in the trees. Breezy
- Duration- I>E
- Located over peripheral lung fields.
- Often stated as clear breath sounds.
Bronchiovesicular Sounds
- Normal
- Duration- I=E. Inspiration is louder.
- Location- over major bronchi, Posterior- between scapulae, anterior-upper sternum 1st-2nd intercostal space.
Bronchial (Tracheal) Sound
- Normal
- Location- over the trachea.
- Duration- I
Adventitious Sounds
Added sounds that are not normally heard in the lungs. I.E. crackles, wheezing.
-If heard describe them as inspiratory versus expiratory, loudness, pitch, and location on the chest wall.
Crackles
- Caused by fluid in the lungs
- Discontinuous sound because it comes and goes.
Coarse Crackles
- More fluid in the lungs
- Start in early expiration and may be present in expiration.
- May decrease with suctioning or coughing but reappear.
Pleural Friction Rub
- Caused by inflammation of pleural space.
- Tissue is rubbing together.
- Discontinuous sound
- Coarse and low pitched. Grating quality-sounds like leather is being rubbed together.
Stridor
- Upper airway occlusion
- Crowing sound
- Continuous- Starts with inspiration and continues to the start of expiration.
Wheeze
- High pitched. (Sibilant)
- Musical
- Continuous- end of inspiration and continues through expiration.
- Cause by airway tightness due to constriction
Sonorous Rhonchi
- Low pitched
- continuous- end of inspiration to the end of expiration.
- Gunk in chest due to infection
- Cleared by coughing
Bronchophony
- Ask patient to repeat “99” as you LISTEN over the chest wall.
- Normal: soft, muffled, indistinct.
- Abnormal: sound mor distinct over areas of increased density. (consolidated areas i.e pneumonia, tumor)
Egophony
- Ask patient to repeat “E” while you LISTEN over the chest wall.
- Normal: soft, muffled, hear “e”
- Abnormal: sounds louder, changes to “a” over areas of consolidation.
Whispered Pectoriloquy
- Ask patient to whisper “123” as you listen over lungs
- Normal: faint, muffled, almost inaudible
- Abnormal: clear, distinct (like whispering directly into the stethoscope) over areas of consolidation.
