Thorax and Lungs

Question 1

Health Hx Questions

Answer 1

cough, SOB, chest pain with breathing, wheezing, stridor, cyanosis, past hx respiratory infections, smoking hx, environmental exposure, self-care behaviors

Question 2

Tobacco Use Hx

Answer 2

#packs/day x years = pack year hx
always offer cessation support

Question 3

Cough

Answer 3

beneficial reflex, abnormal if persistent or recurrent

Sputum or phlegm - always abnormal

Question 4

bacterial pneumonia

Answer 4

phlegm rusty pink

Question 5

expectoration in AM

Answer 5

positional, chronic bronchitis

Question 6

Hemoptysis

Answer 6

expectoration of blood or blood-tinged from respiratory tract, must differentiate if from resp or GI
coughed up usually bright red, alkaline, mixed with frothy
GI dark, acidic and with food

Question 7

SOB (dyspnea)

Answer 7

Left sided heart failure: can be slowly progressing or acute
COPD: slowly progressing
Asthma: acute episode with nocturnal episodes common
Pneumonia: depends on causative agent, acute or progressive
Spontaneous Pneumothorax: sudden onset
Pulmonary emboli: sudden onset
Anxiety with hyperventilation: episodic, recurrent

Question 8

Chest pain with breathing

Answer 8

Pain caused by pulmonary disorder originates in pleura, airways, or chest wall

Question 9

Pain: Pleura

Answer 9

stretch during inspiration, localized, may hear rub

Question 10

Pain: Airways

Answer 10

pronounced after coughing, occurs w/ infection and inflammation of trachea or bronchi

Question 11

Pain: Chest wall

Answer 11

muscle or rib pain, trauma, excessive coughing, rib fracture, muscle sore

Question 12

Inspection

Answer 12

Facial expression and breathing effort
Count respirations
quality of resp.
skin abn and color

Question 13

Estimate diameter of chest wall

Answer 13

AP/Lateral 1:2

inc in aging and COPD

Question 14

Inspect posterior chest

Answer 14

shape
movement
deformities/assymetry –> pleural effusion
abn retraction –> asthma, COPD, upper obstruction
impaired movement

Question 15

Configurations of the thorax

Answer 15

Normal
Barrel chest
Scoliosis
Pectus Excavatum
Pectus Carinatum
Kyphosis

Question 16

Respiratory Excursion

Answer 16

symmetry

accessory muscle involvement, retraction

Question 17

Tactile Fremitis

Answer 17

say “99”

Question 18

Percuss for symmetry

Answer 18

Resonant - normal
Hyperesonant - increased air (COPD, pneumothorax)
Tympany - air-filled, viscous (stomach, intestine) or pneumothorax
Dull - dense tissue, penumonia
Flat - no air present, over bone, pleural effusion

Question 19

Diaphragmatic Excursion

Answer 19

distance between level of dullness on full expiration and level of dullness on full inspiration
normal 3.5-5 cm
Abnormally high level may indicate pleural effusion or high diaphragm as in atelectasis or phrenic nerve paralysis

Question 20

Auscultate Breath sounds

Answer 20

Vesicular breath sounds
Adventitious breath sounds
Crackles or Rales
Wheezing
Rhonchi

Question 21

Vesicular Sounds

Answer 21

Vesicular - inspiratory longer than expiratory
Bronchovesicular - insp = exp (anteriorly)
Bronchial - exp longer (over manubrium)
Tracheal - insp and exp sounds equal (over trachea and neck)

Question 22

Crackles (Rales)

Answer 22

discontinuous
intermittent, nonmusical, brief
fine
coarse
Abnormalities of lung: pneumonia, fibrosis, heart failure
Abn of airway: bronchitis

Question 23

Wheezes and Rhonchi

Answer 23

continuous
musical, prolonged
Wheezes: high pitched with hissing or shrill
asthma, COPD, bronchitis

Rhonchi: low pitched with snoring quality
suggestive of secretions

Question 24

Stridor

Answer 24

high pitched crowing with inspiration
indicates obstruction - EMERGENCY
croup, upper airway obstruction
Acute Epiglotitis - do not look in mouth, collapsed airway

Question 25

Transmitted sounds: Egophany

Answer 25

Egophany - say ee, should hear muffled long E, if turns to a then suspect pneumonia

Question 26

Transmitted sounds: Bronchophony

Answer 26

say 99 if heard increased transmission of voice sounds, lungs not filled with air -PE, pneumonia, or tumor

Question 27

Transmitted sounds: Whispered petoriloquy

Answer 27

ask to whisper 99 normally not heard increased sound increased sound with consolidation

Question 28

Normal Lung

Answer 28

``` Trachea - midline Tactile Fremitus - normal Percussion - resonant Breath Sounds - vesicular except over bronchi or trachea Adventitious sounds - non ```

Question 29

Asthma

Answer 29

Inspection – anxious , labored breathing, exhalation prolonged, audible wheezing, retraction of respiratory muscles, cough Palpation- decrease tactile fremitus Percussion - resonant or hyperresonant, excursion may be limited Auscultation – prolonged expiration, wheezes, diminished breath sounds

Question 30

Bronchitis

Answer 30

Inspection- may be normal or rasping cough in acute; plethoric appearance with wheezing in chronic Palpation – normal fremitus Percussion- normal resonance Auscultation- normal breath sounds, but coarse crackles or rhonchi may be present.

Question 31

Chronic Bronchitis, COPD

Answer 31

- sputum most days for 3mo for 2 consecutive years - exposed to tobacco smoke or inhaled irritants - dyspnea, fatigue, or cyanosis - inspection- flush face often wheezing - cough rattling sound, fremitus normal or inc - percussion resonant to hyperres. - auscultation - prolong expiratory phase and usually crackles

Question 32

Emphysema COPD

Answer 32

Inspection - increased AP/L diameter, barrel chest, use of accessory muscles to aid respiration Palpation- tactile fremitus decreased, chest expansion decreased Percussion – hyperresonant, excursion decreased Auscultation – breath sound decreased with prolonged expiration, occasional wheezes, and fine crackles

Question 33

Atelectasis (Lobar obstruction) (collapsed lung)

Answer 33

Inspection – trachea deviation toward affected side Palpation – expansion decreased on affected side; fremitus decreased to absent Percussion –dull over area involved Auscultation – decreased vesicular breath sounds; wheezes, rhonchi and crackles depending on extent of collapse

Question 34

Consolidation (filled with fluid)

Answer 34

Inspection – increase rate, guarding Palpation -fremitus increased, expansion limited Percussion- dull over airless area Auscultation - breath sounds louder in intensity with bronchovesicular or bronchial sounds over affected area, inspiratory crackles Bronchophony, egophony, whispered pectoriloquy present

Question 35

Pleural Effusion

Answer 35

Inspection – increased rate, dyspnea Palpation –expansion decreased on affected side, fremitus decreased or absent Tracheal deviation maybe present Percussion – dull to flat, no excursion of affected side Auscultation – breath sounds decreased or absent, voice sounds decreased or absent; no adventitious sounds *trachea deviated

Question 36

Pneumothorax

Answer 36

EMERGENCY Inspection –restricted lung expansion on affected side, tachypnea, respiratory distress, Tracheal deviation to opposite side Palpation – diminished or absent tactile fremitus, Percussion- hyperresonant, decreased diaphragmatic excursion Auscultation- breath sounds usually decreased or absent; no adventitious sounds Possible pleural rub