Thorax/Lungs

Question 1

List potential causes of nail clubbing and explain their significance.

Answer 1

Clubbing is associated with a variety of respiratory and cardiovascular diseases, cirrhosis, colitis, and thyroid disease.

Question 2

Describe inspection findings suggestive of respiratory distress.
4

Answer 2

Barrel chest: AP diameter approaches or equals the lateral diameter – compromised respiration as in, for example, chronic asthma, emphysema, or cystic fibrosis

Tachypnea/Shallow breathing

Pursing of the lips: increased expiratory effort

Flaring of the alae nasi: during inspiration is a sign of air hunger

Question 3

Tachypnea

Answer 3

Persistent respiratory rate > 20 breaths per minute (in adult) – could be d/t examiner watching if not persistent; symptom of protective splinting from the pain of a broken rib or pleurisy; Massive liver enlargement or abdominal ascites may prevent descent of the diaphragm and produce a similar pattern

Question 4

Bradypnea:

Answer 4

a rate slower than 12 respirations per minute – neurologic or electrolyte disturbance, infection, or a conscious response to protect against the pain of pleurisy or other irritative phenomena OR excellent level of cardiorespiratory fitness.

Question 5

Dyspnea

Answer 5

difficult and labored breathing with shortness of breath – pulmonary or cardiac compromise, sedentary lifestyle/obesity

Question 6

Orthopnea

Answer 6

shortness of breath that begins or increases when the patient lies down; ask whether the patient needs to sleep on more than one pillow and whether that helps.

Question 7

Paroxysmal nocturnal dyspnea

Answer 7

a sudden onset of shortness of breath after a period of sleep; sitting upright is helpful.

Question 8

irregular respirations

Hyperpnea

Answer 8

exercise, anxiety, CNS dz, metabolic dz, acidosis, aspirin poisoning, hypoxemia, pain

Hyperventilation

Question 9

irregular respirations

Hypopnea

Answer 9

Abnormally shallow respirations – pleuritic pain

Question 10

irregular respirations

Air trapping

Answer 10

If the pulmonary tree is seriously obstructed for any reason, inspired air has difficulty overcoming the resistance and getting out.

Result of a prolonged but inefficient expiratory effort – also increased resistance (i.e. chronic bronchitis), decreased elastic recoil of the lung (i.e., emphysema) or a drop in the critical closing pressure of the airway (i.e., asthma); resp rate increases to compensate (more shallow and air trapping increases - lung hyperinflation = barrel chest)

Question 11

irregular respirations

Periodic breathing:

Answer 11

regular periodic pattern of breathing with intervals of apnea followed by a crescendo/decrescendo sequence of respiration – during sleep, seriously ill, particularly those with brain damage at the cerebral level, with drug-associated respiratory compromise or severe congestive heart failure

Question 12

irregular respirations

Kussmaul respirations

Answer 12

always deep and most often rapid – respiratory effort associated with metabolic acidosis.

Question 13

irregular respirations

Biot/Ataxic

Answer 13

irregular respirations varying in depth and interrupted by intervals of apnea, but lacking the repetitive pattern of periodic respiration – severe and persistent increased intracranial pressure, respiratory compromise resulting from drug poisoning, or brain damage at the level of the medulla and generally indicates a poor prognosis

Question 14

AP:transverse thorax diameter

HEALTHY ADULTS:

Answer 14

The AP diameter of the chest is ordinarily less than the lateral diameter – thoracic ratio and is expected to be about 0.70 to 0.75

Question 15

AP:transverse thorax diameter

INFANTS

Answer 15

chest of the newborn is generally round, the AP diameter approximating the lateral diameter, and the circumference is roughly equal to that of the head until the child is about 2 years old

Question 16

AP:transverse thorax diameter

OLDER ADULTS:

Answer 16

The barrel chest that is seen in many older adults results from loss of muscle strength in the thorax and diaphragm, coupled with the loss of lung resiliency. In addition, skeletal changes of aging tend to emphasize the dorsal curve of the thoracic spine, resulting in an increased AP chest diameter. There may also be stiffening and decreased expansion of the chest wall.

Question 17

anatomical changes of chest/thorax

PREGNANT:

Answer 17

Anatomic changes that occur in the chest as the lower ribs flare include an increase in the lateral diameter of about 2 cm and an increase in the circumference of 5 to 7 cm. The costal angle progressively increases from about 68.5 degrees to approximately 103.5 degrees in later pregnancy.

Question 18

AP:transverse thorax diameter

ABNORMALITIES:

Answer 18

compromised respiration as in chronic asthma, emphysema, or cystic fibrosis

Question 19

TECHNIQUE: To evaluate thoracic expansion during respiration

Answer 19

To evaluate thoracic expansion during respiration, stand behind the patient and place your thumbs along the spinal processes at the level of the tenth rib, with your palms lightly in contact with the posterolateral surfaces. Watch your thumbs diverge during quiet and deep breathing. A loss of symmetry in the movement of the thumbs suggests a problem on one or both sides.

Question 20

SIGNIFICANCE of assessing thoracic chest expansion

Answer 20

A patient who is barrel-chested with chronic obstructive pulmonary disease may not demonstrate this. The chest is so inflated that it cannot expand further and your hands may even come together a bit

Question 21

subcutaneous crepitus (subcutaneous emphysema).

Answer 21

CREPITUS: a crackly or crinkly sensation, can be both palpated and heard—a gentle, bubbly feeling.
→ indicates air in the subcutaneous tissue from a rupture somewhere in the respiratory system or by infection with a gas-producing organism (always pathologic)

Question 22

technique to assess tactile fremitus

Answer 22

Fremitus is best felt posteriorly and laterally at the level of the bifurcation of the bronchi. Ask the patient to recite a few numbers or say a few words (“99” is a favorite, as is “Mickey Mouse,” depending perhaps on the age) while you systematically palpate the chest with the palmar surfaces of the fingers or with the ulnar aspects of the hand. Use a firm, light touch, establishing even contact. For comparison, palpate both sides simultaneously and symmetrically; or use one hand, alternating between the two sides. Move about the patient, palpating each area carefully, right side to left side.

Question 23

Decreased or absent fremitus:

Answer 23

excess air in the lungs, emphysema, pleural thickening or effusion, or bronchial obstruction.

Question 24

Increased fremitus:

Answer 24

often coarser or rougher in feel – presence of fluids or a solid mass within the lungs and may be caused by lung consolidation, heavy but non-obstructive bronchial secretions or compressed lung.

Question 25

Gentle more tremulous fremitus:

Answer 25

lung consolidations, inflammatory and infectious processes

Question 26

Hyperresonance of thorax

Answer 26

abnormal sound, the result of air trapping; emphysema, pneumothorax, or asthma

Question 27

Dullness or flatness of thorax

Answer 27

pneumonia, atelectasis, pleural effusion, or asthma.

Question 28

thoracic excursion distance

Answer 28

The excursion distance is usually 3 to 5 cm

The diaphragm is usually higher on the right than on the left because it sits over the bulk of the liver.

Question 29

Bronchial breath sounds

Answer 29

Heard only over trachea; high pitch; loud and long expirations, sometimes a bit longer than inspiration

Question 30

Bronchovesicular breath sounds

Answer 30

Heard over main bronchus area and over upper right posterior lung field; medium pitch; expiration equals inspiration

Question 31

Vesicular breath sounds

Answer 31

Heard over most of lung fields; low pitch; soft and short expirations; more prominent in a thin person or a child, diminished in the overweight or very muscular patient

Question 32

Crackles (rales):

Answer 32

Discontinuous; fine crackling, high pitched

Question 33

Rhonchi:

Answer 33

loud, low, coarse sounds like a snore most often heard continuously during inspiration or expiration; coughing may clear sound (usually means mucus accumulation in trachea or large bronchi)

Question 34

Wheezes:

Answer 34

musical noise most often heard continuously during inspiration or expiration; usually louder during expiration

Question 35

Pleural friction rub:

Answer 35

dry, rubbing, or grating sound, usually caused by inflammation of pleural surfaces; heard during inspiration or expiration; loudest over lower lateral anterior surface

Question 36

Mediastinal crunch (Hamman sign):

Answer 36

found with mediastinal emphysema – great variety of sounds (loud crackles, clicking, and gurgling sounds) are heard over the precordium. They are synchronous with the heartbeat and not particularly so with respiration.
These sounds can be more pronounced toward the end of expiration and are easiest to hear when the patient leans to the left or lies down on the left side.

Question 37

disorders that result in diminution of breath sound and explain clinical significance

Answer 37

Fluid or pus has accumulated in the pleural space, secretions or a foreign body obstructs the bronchi, breathing is shallow from splinting due to pain, or the lungs are hyperinflated such as occurs in severe obstruction from asthma or chronic obstructive pulmonary disease (COPD)

Emphysema, Pleurisy (often result of PE), Pneumonia, Bronchiolitis, Hemothorax, lung abscess, pleural effusion, pneumothorax, COPD

Question 38

Describe three tests for identifying abnormal vocal resonance and list disorders associated with increased vs. decreased vocal resonance.

Answer 38

Broncophony- 123 with increasing clarity
Egophony- e sounds like a
Whispered pectoriloque - if you can hear the whisper

Question 39

Identify conditions which may alter the inspiratory:expiratory (I:E) ratio and explain clinical significance.

Answer 39

Airway obstruction: I/E > 2/1

Stridor heard with I/E > 3:1
→ floppy epiglottis, congenital defects, croup, edematous response, aspirated foreign body, abscess, tumor, double aortic arch