Chest Exam: Thorax and Lungs Flashcards Preview

Physical Diagnosis > Chest Exam: Thorax and Lungs > Flashcards

Flashcards in Chest Exam: Thorax and Lungs Deck (50)
1

Thorax landmarks: Anterior and Posterior

Anterior
-Rib cage, sternum, suprasternal notch, clavicle, nipples
-Sternal angle (Angle of Louis) @ 2nd intercostal space
-Imaginary reference lines
Posterior
-C 7
-Tip of scapula @ 7th intercostal space
-Imaginary reference lines

2

Thorax landmarks: Ribs

Ribs 1-7 attached to sternum
Ribs 8-10 attach to cartilage of rib above
“Floating” ribs – 11 & 12
Costal (costophrenic) angle anterior
Costovertebral angle (CVA) posterior

3

Reference lines

Anterior thorax
-Mid sternal line
-Mid clavicular line
-Nipple line (T4)

Lateral thorax
-Anterior axillary line
-Midaxillary line
-Posterior axillary line

Posterior thorax
-Vertebral line
-Midscapular line

4

diaphragm

dome shaped muscle located at base of lung fields, primary breathing muscle
Moves down/contracts with inspiration, up/relaxes with expiration

5

lung apex location

2-4 cm above inner third of clavicle

6

Lower border of lung (during inspiration) location

6th rib anteriorly MCL
T10 posteriorly MSL

7

pleural fluid

between parietal and visceral pleura
allows lungs to move easily with inspiration and expiration

8

how pain is felt in lungs

Pleural space has pain fibers (irritants…inflammation…pain)
Lung tissue itself has no pain fibers; however, surrounding structures do (ie: pleura, muscles, bones)

9

repiratory inspection

-Check for Respiratory Difficulty
-Assessment of color
-Observe patient’s posture
-Inspect the nose for nasal flaring
-Inspect the neck for accessory muscle use
-Inspect the rib cage for retractions
-Observe the shape of the chest, AP diameter

10

thorax inspection

Anterior & Lateral
-Ratio of anterior/posterior to lateral (transverse) diameter is normally 1:2
-Symmetry of respiratory movements

Posterior
-Deformity or spinal curvature
-Symmetry of respiratory movements

11

barrel chest

COPD, emphysema, and chronic bronchitis

12

kyphosis

elderly and can be congenital
can impact lung function

13

pectus excavatum

caved in chest wall
congenital abnormality
can impact lung development and lead to respiratory problems

14

pectus carnatum

less of an issue with lung function

15

palpation of thorax

Assess for :
-Masses
-Tenderness
-Crepitus
-Respiratory Expansion
-Tactile Fremitus

16

Respiratory expansion

-Indicates equal expansion of lungs during a normal respiratory cycle
-Assesses compliance of lungs, pleura and chest musculature
-Place thumbs at level of the 10th ribs
Slide hands medially…raise loose fold of skin.
Ask pt to inhale deeply
Watch thumbs move apart at pt inhale
Feel for symmetry and range of rib cage as it expands and retracts

17

tactile fremitus

-Use either ball or ulnar aspect of hand
-Ask the patient to say “99” or “1-1-1”
-Examine the Fields
--Four fields posteriorly
--Three fields anteriorly
-Palpable vibrations transmitted from the bronchopulmonary tree to the chest wall
-Look for asymmetrical difference in the intensity of the vibratory sensation
-More solid areas of lung will transmit more vibrations (Increased fremitus suggests fluid, mass, pneumonia)

18

percussion

-Screen the ant/lat/post thorax noting any change in the normal resonant sound
-Helps to determine if structures are air filled, fluid filled, or solid
-Compare bilaterally moving side to side

19

percussion sound: resonant

healthy lung tissue

20

percussion sound: flat/dull

effusion or consilidation (fluid or solid has replaced air containing lung or occupies pleaural space)

21

percussion sound: hyper-resonant

emphysema, pneumothorax, acute asthma

22

percussion sound: tympanic

large pneumothorax

23

auscultation

-Assess air flow through tracheobronchial tree
-Listening to sounds generated by breathing
-Listening for adventitious (added) breath sounds
-If you hear abnormal breath sounds, you should then listen to spoken/whispered voice sounds as they are transmitted through the chest wall

24

auscultation sound transmission

-Normal air-filled lung acts as a filter to sound
-Lung pathology will alter the sound transmission

25

normal tracheal breath sounds

-Heard directly over trachea and neck
-Very loud/high pitched
-Expiratory/inspiratory component equal

26

normal bronchial breath sounds

-Heard directly over a major bronchus
-Loud/high pitched
-Short silence between inspiration & expiration with expiration lasting longer

27

normal bronchovesicular breath sounds

-Heard best in 1st and 2nd ICS anteriorly and between scapula posteriorly
-Medium pitch
-Equal inspiration/expiration

28

normal vesicular breath sounds

-Heard over lung fields
-Soft low pitch
-Inspiration last longer than expiration

29

rales/crackles

-Intermittent, nonmusical dots in time
-Can be fine or coarse, dry or wet
-Crackling noises caused by deflated, fluid filled small airways popping open with air
-Can be heard with pneumonia, fibrosis, bronchitis

30

wheezes/rhonchi

-Musical continuous sounds
-Wheezes suggest narrowed bronchi
-Rhonchi suggest secretions

31

stridor

Stridor: high pitched wheeze during inspiration that is louder at the neck, indicates upper airway obstruction

32

pleaural friction rub

Pleural Friction Rub: discrete “creaking noise” confined to one area, caused by pleural surfaces grating against each other

33

mediastinal crunch

Mediastinal Crunch: (Hamman’s sign) precordial crackles caused by air between pleurae

34

bronchophony

-Bronchophony –Ask patient to say “99” and listen with stethoscope
--Normal: sound is muffled by healthy lung
--Increased transmission of voice sound (loud & clear) suggests that air-filled lung has become airless (this is bronchophony)

35

egophony

Egophony – ask patient to say “EE” while listening with stethoscope
If EE is heard as AY and quality is nasal, suggestive of pneumonia or other consolidation

36

whispered pectoriloquy

Whispered Pectoriloquy – ask patient to whisper “99” while listening with stethoscope
Normal: should be barely audible
Easily audible (loud & clear) suggests consolidation

37

summary of lung exam

Inspection
-Position, color, AP diameter, accessory muscle use
Palpation (crepitus, tenderness, mass)
-Anterior, posterior, lateral
-Respiratory expansion
Percussion (resonant sound)
-Anterior (apex), posterior (cross arms), lateral
Auscultation (bronchovesicular sounds)
-Anterior, posterior, lateral

38

peak flow

Forced expiratory flow rate
Assess for obstructive lung
disease (COPD, asthma)

39

common pulmonary diseases

Chronic Obstructive Pulmonary Disease (COPD)
COPD = chronic bronchitis & emphysema
Chronic bronchitis – excessive mucus production in bronchi
Emphysema – over distention of alveoli, with alveolar destruction
Asthma
Pneumothorax
Pneumonia

40

COPD

Physical findings include
-General inspection: clubbing, cyanosis, accessory muscle use
-Thoracic inspection: barrel chested habitus, increased AP diameter
-Percussion: hyperresonant
-Auscultation: decreased breath sounds
--Adventitious sounds – none; or crackles, wheezes and rhonchi

41

Asthma

-Hyper-reactivity of bronchial tree resulting in inflammation, hypersecretions and bronchoconstriction
-No structural or permanent damage
-Can be asymptomatic with exacerbations or
--Mild intermittent
--Mild persistent
--Moderate persistent
--Severe persistent

42

physical findings of asthma

Not during attack
-Normal exam
During attack
-Increased RR, HR; decreased O2 saturation
-Tripod position, cyanosis, accessory muscle use
-Resonant percussion note
-Wheezes on auscultation
-Decreased peak flow

43

pneumothorax

-Air leakage into the pleural space causes pressure gradient between space and lung

44

Tension pneumothorax

is when the entire lung collapses other lung get shifted over and you get tracheal deviation

45

spontaneous pneumothorax

due to spontaneous rupture of bleb (bulla)

46

traumatic pneumothorax

due to penetrating injury to lung from knife, bullet, or rib fragments

47

physical findings of pneumothorax

-Chest rise is asymmetrical
-Hyperresonant percussion note over affected lung
-Breath sounds decreased or absent over affected lung
-Tactile fremitus decreased or absent over affected lung
-Tension pneumo: tracheal deviation

48

Pneumonia

-Inflammation of lung tissue caused by bacterial, viral or mechanical causes
-Alveoli fill with fluid or purulent debris

49

physical findings of a pneumothorax

-Inspection: normal unless respiratory distress
-Percussion: dull percussion note
-Auscultation: bronchial breath sounds, inspiratory rales
-Transmitted sounds (bronchony, egophony and whispered pectoriloquy) present/increased
-Increased tactile fremitus

50

thorax and lung exam checklist

-fully expose the thorax and inspect for symmetry, lesions, effort of breathing
-inspect the lateral thorax for AP diameter
-palpate anterior, posterior, lateral thorax for tenderness, crepitus
-assess respiratory expansion and tactile fremitus ant/post/lat thorax
-percuss ant/post/lat thorax for symmetry and resonance
-auscultate ant/post/lat thorax
-examine patient bilaterally, comparing sides during percussion and auscultation
-instruct the patient properly during exam (arm crossed, mouth open)
-palpate, percuss, and auscultate in correct and sufficient areas for complete exam
-special tests: egophony, bronchophony, whispered pectoriloquy