-
What is the top center of the manubrium termed
suprasternal notch
-
What is the space termed where the manubrium & sternum meet
sternal angle
-
The cardiac notch of the left lung is in what interspace
4th interspace
-
What is the space termed for the angle btwn the 2 ribs
costal angle
-
How should you describe the abnormalities of the chest wall
- vertical axis
- circumference of the chest
-
How do you determine the vertical locations
- count the ribs & interspaces
- sternal angle best guide
-
What intercostal space is used for needle insertion for tension pneumothorax
2nd
-
What intercostal space is used for chest tube instertion
4th
-
What spinous process is the lowest margin for endotrachial tube on chest x-ray
T4
-
Which ribs articulate with the sternum
1st seven
-
Which ribs articulate with the costal cartilages superior to them
8,9,10
-
Name the floating ribs
11,12
-
Where is the inferior tip of the scapula
7th rib interspace
-
how do you locate findings around chest circumference
vertical lines
-
Which two lines are precise
midsternal & vertebral
-
where does the midclavicular line drop to
midpoint of clavicle
-
where does the ant & post axillary lines drop
vertically from ant & post axillary folds
-
where does midaxillary line drop
apex of axilla
-
vertebral line overlies what
spinous processes
-
scap line drops
inf angle scapula
-
How high does the apex of each lung go
2-4 cm above inner 3rd clavicle
-
how low does lower border of rib go
- crosses 6th ribs at midclavicular line
- 8th ribs midaxillary line
- post=T10
-
What divides the lungs in half
oblique (major) fissure
-
Additionally the right lung is further div by
horizontal fissure (minor)
-
Fissures div lungs into
lobes
-
What is the approximated location of the oblique fissure
T3 down & around chest 6th ribs midclavicular line
-
What is the approximated location of the horizontal fissure
ant=4th ribs meets obl fiss at midax line 5th rib
-
where does the trachea bifurcate into mainstem bronchi
level of sternal angle ant & T4 post
-
A serous membrane that cover outer surface of each lung
visceral pleura
-
what covers the inner rib cage & upper surface of diaphragm
parietal pleura
-
What are the common or concerning symptoms of the thorax
- chest pain
- dyspnea
- wheezing
- cough
- hemoptysis
-
What should your intial question be for chest pain
Do you have any discomfort or unpleasant feelings in chest & have them point to location of pain. try to elicit 7 attributes symptom
-
Chest pain may come from other areas besides the lungs including
- cardiac
- vascular
- GI
- musclesk
- skin
- anxiety
-
How is pain in the lungs determined
inflammation of adj parietal pleura
-
What does a clenched fist over sternum suggests
angina
-
A finger pointing to a tender area on chest wall suggests
muscle sk pain
-
A hand moving from neck to epigastrum suggests
heartburn
-
Most frequent cause of chest pain in children
anxiety or costochondritis
-
what is dyspnea
shortness of breath
-
A nonpainful but uncomfortable awareness of breathing that is inappropriate to level of exertion
dyspnea
-
How do you start your questioning with dyspnea
Have you had any difficulty breathing
-
How do you determine the severith of dyspnea
by patients daily activities=quantify for example how many stairs they can walk up before pausing for breath
-
Musical resp sounds that may be audible to the patient or to others
wheezing
-
What does wheezing suggests
partial airway obstruction-secretions, tissue inflammation;foreign body
-
A reflex response to stimuli that irritate receptors in larynx, trachea or lrg bronchi or cardiovasc orgin
cough
-
A cough may be a symptom of what type of heart failure
left-side
-
A good question to ask about cough
Does the cough produce sputum, phlegm or is it dry
-
What is important for patient to explain to the clinician about cough
vol sputum & its color odor, consistency
-
what is most common cause of acute cough
URI
-
Coughing up blood from the lungs
hemoptysis & it varies from blood streaked phlegm to frank blood
-
How you should as the clinician address the patient about hemoptysis
have them describe vol blood produced & sputum Battributes
-
Blood originating in the stomach will look how
darker than blood from resp tract
-
What are some important topics for health counseling & promotion
- tobacco cessation
- immunizations
-
When addressing tobacco cessation how should you go about addressing the issue of usage
- Ask about smoking
- Advise them to stop
- Assess their readiness to quit
- Assist them with stop dates & educational resources
- Arrange follow-up visits
-
how often should you advise patients to get a flu shot
1 dose annually in fall or winter
-
how often should you adive patients to get a pneumococcal vacine
- 65 years & older if 1st dose was given prior to age 65 & 5 yrs have elapsed since 1st dose
- 2-64 with chronic illnesses
- anyone w/cochlear implant
- immunocompromised
- native americans
-
how often should patients get a Tdap
never had one or dealing with infants younger than 12mos, healthcare personnel,over 65 with risk indicator
-
how should you examine post thorax
patient sitting
-
how should you examin ant thorax
patient supine
-
How should you proceed in an orderly fashion
- inspect
- palpate
- percuss
- ausculatate
-
What is the intial survey of respiration & the thorax
observe rate, rhythm, depth, effort of breathing
-
What do yo want to look for when inspecting for signs of resp difficulty
-
how do you want to assess the patients color
looking for cyanosis which could signal=hypoxia
-
What is a high pitched wheeze that is an obvious sign of airway obstruction in larynx or trachea
audible stidor
-
Inspiratory contraction of SCM & scalens at rest signifies
severe difficulty in breathing
-
Lateral displacement of trachea could signal
- pneumothorax
- pleural effusion
- atelectasis
-
Why is it important to observe the shape of the chest/Ap diameter
Ap diameter may increase in COPD
-
How do you want to inspect the posterior chest
note the shape chest & way it moves
-
What to look for with palpation
abnormalities & tender areas
-
How do you test for chest expansion
thumbs at 10th rib & fingers loosely grasping & parallel to lat rib cage watch the distance btwn thumbs as they move apart during inspiration
-
What does fremetis refer to
palpable vibrations transmitted through bronchopulm tree to chest wall as the patient speaks
-
What does percussion help to establish
underlying tissues are air-filled, fluid-filled or solid
-
What are the different percussion notes
- flat
- dull
- resonance
- hyperresonance
- tympany
-
What type of percussion do you want to use
lightest that produces a clear note
-
How do you want to percuss
- side to side to assess for asymmetry
- strike using tip of your finger
-
Healthy lungs have what type of percuss sound
resonant
-
gastric air bubble or puffed out cheek sound with percuss
tympany
-
Thigh produces what kind of percuss sound
flat
-
liver produces what kind of percuss sound
dull
-
What replaces resonance when fluid or solid tissue replaces air containing lung or occupies pleural space beneath percussing fingers
dullness
-
pathologic example of flatness
lrg pleural effusion
-
pathologic example of dullness
lobar pneumonia
-
pathologic example of resonance
simple chronic bronchitis
-
pathologic example of hyperresonance
copd & pneumothorax
-
pathologic example of tympany
lrg pneumothorax
-
Diaphragmatic excursion
estimate extent by the descent of diaphragm to determine level of diaphragmatic dullness in quiet respiration=5-6cm
-
most important examination for assessing air flow through tracheobronchial tree
auscultation
-
What does auscultation & percussion assess
condition of surrounding lungs & pleural space
-
What are the normal breath sounds
- vesicular
- bronchial
- bronchovesicular
-
soft & low pitched heard over most of both lungs
vesicular
-
louder & higher in pitch usually heard over manubrium
bronchial
-
intermediate intensity & pitch heard over 1st & 2nd interspaces
bronchovesicular
-
very loud harsh sounds heard over trachea
tracheal
-
What are the adventitious sounds
-
discontinous intermittent nonmusical & brief sounds
crackles/rales
-
continious musical prolonged but not persisting throughout resp cycle
wheezes & rhonchi
-
wheezes suggest narrowed airways as in
-
What does rhonchi suggest
secretions in lrg airways
-
How to exam the anterior chest
inspect & auscultate
-
spoken ee heard as ay suggest
egophony
-
whispered words louder & clearer
whispered pectoriloquy
-
how is tactile fremetis in a normal air filled lung vs airless lung with the case of lobar pneumonia
- normal=normal
- airless=increased due to alveoli filled w/fluid, rbc's, wbc's=consolidation
-
what are some other causes of increased tactile fremitus
pulm edema or hemorrhage
-
Tactile fremitis is normal in what conditions
- normal
- chronic bronchitis
- left side Heart failure
-
Tactile fremitus is decreased in the following conditions
- pleural effusion
- pneumothorax
- COPD
- Asthma
-
What conditions produce a resonaut sound with percussion
- normal
- chronic bronchitis
- left side heart failure
-
what conditions produce a dull over airless area with percussion notes
- consolidation
- atelectasis=lobar obstruction
-
what condition produces a percussion note of dull to flat over fluid
pleural effusion
-
what condition produces a percussion note of hyperresonaut or tympanitic over pleural air
pneumothorax
-
what condition produces a diffusely hyperresonaut percussion note
COPD
-
what condition produces a resonaut to diffusely hyperresonant percussion note
asthma
-
The trache stays in midline in all of the following conditions
- normal
- Chr Br
- LSHF
- cons
- COPD
- Asthma
-
trachea may be shifted toward involved side in what condition
atelectasis
-
trachea is shifted toward opposite side in large effusion in what condition
pleural effusion
-
trachea is shifted toward opposite side if much air in what condition
pneumothorax
-
normal breath sound
vesicular
-
Chronic bronchitis breath sound
vesicular
-
LSHF breath sound
vesicular
-
consolidation breath sound
bronchial
-
atelectasis breath sound
- absent=bronchial plug persists
- other=tracheal maybe
-
pleural effusion breath sound
decreased to absent but bronchial near top
-
pneumothorax & copd breath sounds
decreased to absent
-
asthma breath sounds
often obscured by wheezes
-
normal cond advent sounds
none but maybe transciet crackle at lung base
-
Chr Bron adven sounds
none or scattered crackles in early inspriation/exp or wheezes/rhonchi
-
adventious sounds in LSHF
late insp crackles w/possible wheezes
-
adventious sounds in consolidation
late insp crackles
-
advent sounds in atelectasis
none
-
pleural effusion & pneumothorax advent sounds
none except possible pleural rub
-
advent sounds of copd
none or crack,wheeze/rhonchi of associated chr bron
-
advent sounds asthma
wheezes possibly crackles
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