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193 Cards in this Set

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Hi guys, these cards are for Dr. Scott's Lung Section.
kcb
Four major components of the lung exam
Inspection
Palpation
Percussion
Auscultation
Inspection
Watch Breaths-rate, rhythm, depth and effort
Accessory mm-SCM, platysma, scalenes
Prolonged expiratory phase=COPD issues
Finger clubbing=lung abscesses, malignancy, congential heart dz
Color of pt-cyanosis anywhere(esp mouth)=late sign in hypoxia
Postural position of pt-sitting upright, tri-pod position
Pursed lips
Ability to speak
Noises w/breathing
Abd wall movement on inspiration
Chest or spine deformities
Paradoxical breathing
With severe diaphragmatic flattening or paralysis, the abd wall may move inward during inspiration. Place your hand on the person's abd and you'll feel the flattening
Rectus excavatum
congenital posterior displacement of lower aspect of sternum. gives chest a "hollowed-out" appearance. x-ray shows a suble concave appearance of the lower sternum.
Barrel Chest
Increased (ant - post) AP diameter
Diaphragmatic flattening
Associated with emphysema (COPD, aging and lung hyperinflation
T1 is about what level?
T12 is about what level?
T1 = clavicles
T12 = umbilicus
Palpation
Detecting Chest Excursion
Tactile Fremitus
Investigating Painful Areas
Detecting Chest Excursion
Do in 3 places
Place hands on back w/thumbs pointed toward spine.
Look for sym or asym expansion
Asym = pleural dzes (has to be a lot of pleural effusion b4 asym can be seen)
Tactile Fremitus
Place hands on back...use ulnar sides of hands and have pt say 99. Do this over entire lung fields. NL lung transmits a palpable vibratory sensation to the chest wall upon saying 99. Pathology alters fremitus.
Pathological Tactile Fremitus
Lung consolidation
Occurs when NLly air filled lung parenchyma becomes engorged with fluid or tissue-ie pneumonia. Alters transmission of air and sound.
Presence = fremitus becomes more pronounced.
Pathological Tactile Fremitus
Pleural Effusion (fluid)
Fluid collects in the potential space that exists btwn the lung and the chest wall, displacing the lung upwards.
Presence = fremitus becomes decreased.
Investigating Painful Areas
Palpate area of pain
Rib fracture
SubQ air (rice crispies)
Percussion
5 percusses/lung=cover lung
Usually will see the changes as you go down the lung field. (More resonant at top, more dull at bottom)
Compare Lt to Rtof both and top to bottom of one.
Resonant note = Over air-filled structure(NL lung)
Dull sound = Over fluid or tissue-filled cavity
Deadened tone = If NL lung is displaced by fluid or infiltrate with WBCs and bacteria
Hyperresonant(drum-like) = air-trapping in lung or pleural space
Auscultation
4 auscultates/lung=cover lung
Have pt breath slowly and deeply through mouth. Go from top of left to top of right, then move done on right and go to left...comparing left to right as you go down
Lungs cover the space of what ribs?
1-9 ish
T1-9
Atelectatic
Areas at the lung bases
Collapsed
Small stelectatic areas at the base of the lungs can sometimes be opened up by coughing.
Vescicular Breath sounds
NL inspiration/expiration
Ins-soft sounds of air rushing in
Exp-little sounds with exp
Wheezes
Whistling/Musical noises w/exp, mostly when air is forced through airways narrowed by bronchoconstriction from tissue inflammation or tumors, secretions or asso mucosal edema
Frequently audible in all lung fields
I:E = 1:2 NL
1:>2 ABNL
Increased Exp = worse obstruction
Focal Wheezes = occurs when airway narrowing restricted to single area (ie-tumor or pneumonia)
Wheezing heard only in inspiration = what?
Stridor
Stridor is associated with what?
Mechanical Obstruction at the level of the trachea/upper airway
Heard best @ top of trachea
Rales (aka crackles)
Sounds like rubbing strands of hair together
Scratchy sounds from fluid witin alveolar and interstitial spaces b/c of pulmonary edema(occurs first in lower lobes) and pneumonia (in specific regions of the lung).
Dry rales(crackles) like velcro = what?
Pumonary fibrosis
Very little sound
Severe, stable emphysema
Lung destruction and air trapping
Tubular or bronchial breath sounds
Dense consolidation in lungs = large airway noises heard over trachea
Snorkel sounds
Egophony
Egophony
Say "eeee" = sounds like "aaaa" over involved lobe
Rhonchi
Secretions in larger airways
Bronchitis
Gurgling noise like sucking last bits of a milkshake
Muffled Breath Sounds
Over pleural effusion
Breath Sounds Packet...
...
What affects breath sounds?
Diameter of airway
Pressure changes in the airway
Vibrations of solid tissue
Describe what happens during inspiration.
Intrapleural pressure decreases b/c intrapleural space increases. Intrapulmonary pressure decreases b/c alveoli are expanding. Intrapulmonary pressure drops below atmospheric pressure = air goes in. Airways are widening which decreases resistance to incoming air.
Describe what happens during expiration.
Lungs contract passively. Both pressures rise and air is forced out of the lungs
Airflow patterns
Turbulent
Circular
Laminar
Turbulent airflow occurs where?
Trachea
Mainstream bronchi
Other larger airways
Turbulent airflow occurs when?
During rapid airflow movement
What produces sound?
Rapid pressure changes within the airway from colliding air molecules
Circular airflow occurs how?
Airflow abruptly changes direction in the branching airways, as it does it separates into layers, each moving at a different speed. Creates vortices.
Vortices
Shearing force of the high-speed airstream against the slower airstream triggers a circulating airflow
How does this airflow pattern generate sound?
As the flow of air carries the vortices "downstream"
Laminar airflow occurs where?
Small airways
Bronchioles
What does this sound like?
no sound b/c no abrupt changes in pressure
Mechanical Vibrations of Sound
Frequency
Intensity
Duration
Frequency
Number of vibrations occurring over a period of time
Frequency
Pitch
Used to describe frequency in clinical setting
High-pitched = high frequency
Love-pitched = low frequency
Intensity
Loudness or softness of the vibrations that produce breath sounds
What does this sound like?
no sound b/c no abrupt changes in pressure
What does this sound like?
no sound b/c no abrupt changes in pressure
Mechanical Vibrations of Sound
Frequency
Intensity
Duration
Mechanical Vibrations of Sound
Frequency
Intensity
Duration
Frequency
Number of vibrations occurring over a period of time
Frequency
Number of vibrations occurring over a period of time
Frequency
Pitch
Used to describe frequency in clinical setting
High-pitched = high frequency
Love-pitched = low frequency
Frequency
Pitch
Used to describe frequency in clinical setting
High-pitched = high frequency
Love-pitched = low frequency
Intensity
Loudness or softness of the vibrations that produce breath sounds
Intensity
Loudness or softness of the vibrations that produce breath sounds
What does this sound like?
no sound b/c no abrupt changes in pressure
Mechanical Vibrations of Sound
Frequency
Intensity
Duration
Frequency
Number of vibrations occurring over a period of time
Frequency
Pitch
Used to describe frequency in clinical setting
High-pitched = high frequency
Love-pitched = low frequency
Intensity
Loudness or softness of the vibrations that produce breath sounds
What is intensity affected by?
Type of structure vibrating
Distance and type of substance through which the vibrations travel
Duration
Length of time vibrations occur
Long or short
Continuous or Discontinuous
Sound Damping
High-pitched breath sounds are damped or absorbed as they travel through the lungs and thorax (air, fluid, tissue)
Impedance
How much a substance resists sound transmission. More resistance = more damping.
What happens when 2 substances are next to each other?
Sound is transmitted effectively
What is an example of this?
When consolidation enhances the transmission of breath sounds to the chest wall
Why does this happen?
Impedance matching
The fluid-filled airless lung tissue that is consolidated and the chest wall are acoustically well matched and breath sounds travel more easily
Mismatch = what?
Ineffectively transmitted sound
Why?
Flui
What is an example of mismatch?
Pleural effusion
Obesity
What is mismatch?
When fluid or solid tissue collects btwn inflated lung segments
What do you hear with Impedance mismatch?
Filtered breath sounds (reduced sounds)
How do you auscultate an obese pt's lungs?
ask pt to breath through mouth while sitting upright or standing
NL Breath Sounds
Over most of chest wall are soft
Vesicular
Broncho-vesicular
Bronchial
Tracheal
Vesicular
Soft and Low pitched
Through Inspiration w/out pause into Expiration
Fades 1/3rd through Exp
Best Heard Over Lungs
I:E ratio 3:1 to 4:1
Broncho-vesicular
Intermediate Sound
Through Inspiration and Exp w/a silent internal between them
Heard Best 1st and 2nd intercostal space anteriorly and between scapulae posteriorly
I:E ratio = 1:1
Bronchial
Louder or High pitched
Exp lasts longer than inspiration w/a short silence btwn them
Best heard over manubrium
I:E ratio = 1:3
Tracheal
Harsh and High pitched
Insp and Exp w/short silence btwn them
Best heard over Trachea
I:E ratio = 1:1
At the beg. of respiration where are breath sounds the loudest?
Apices of lungs
At the end of respiration wher the breath sounds the loudest?
Bases of lungs
5 Adventitious Sounds
1. Crackles/Rales
2. Wheezes
3. Rhonchi
4. Stridor
5. Pleural Rub
Crackles/Rales-why?
rice crispies
a. air bubbles from secretions
b. sudden, explosive opening of the small airways
Crackles/Rales sound like?
Discontinuous
Short, explosive or popping
On inspiration
Crackles/Rales
Characterized by:
Loudness
Number
Timing
Location
Persistance
Changes after cough, movement
Three Types of crackles
1. Late Inspiratory
2. Early Inspiratory
3. Midinspiratory and Expiratory
Late Inspiratory Causes
high-pitched
Atelectasis
Lobar pneumonia
Interstitial fibrosis
Lt-sided heart failure
Early Inspiratory Causes
Course crackles
Chronic bronchitis
Bronchiectasis
Asthma
MidInspiratory and Exp Causes
Bronchiectasis
Wheezes
High-pitched
Continuous
Musical and Prolonged
Wheezes
Characterized by:
Timing
Location
Pitch
Wheezes
Caused by:
Airflow through bronchi that are narrowed nearly to the point of closure
Wheezes
Types
Exp polyphonic
Fixed monophonic
Sequential Inspir
Random monophonic
Wheezes
Causes
Asthma
Chronic Bronchitis
COPD
CHF
Rhonchi
Snoring or gurgling
Musical
Low-pitched
Inp and Exp but more w/Exp
Rhonchi
Causes
Secretions in large airways
Stridor
Emphysema
Inspiration
Louder in neck
Partial obstruction of the larynx or trachea=emergency
Pleural Rub
Creaking sound-like fingers rubbing together
Inflamed and roughened pleural surfaces grate against each other as they are momentarily and repeatedly delayed by increased friction
Sputum Colors
...
White sputum
Lungs are clean
Asthma might be seen
Mucus
Gray sputum
Cold or Flu
Hay Fever Too
Yellow sputum
Purulent
Bronchitis
Bronchiectasis
Black sputum
Smoking crack
Red sputum
blood
CA or TB
Orange Sputum
Pneumococcus
Klebsiella
Green sputum
Purulent
Pseudomonas
Mycoplasma
Brown sputum
Dehydration
See the following sheets with the headings...
(I did not make cards for these sheets)
Comparing Adventitious Breath Sounds
Characteristics of Breath sounds
Locations of NL Breath sounds
T27/T26
ABNL Rate and Rhythm of breathing
Know locations of Lungs...
See sheet "Lung Anatomy & Landmarks"
See sheet...
..."Physical Findings in Selected Chest Disorders"
Health History
Handout
What can chest pain mean?
DDx
R/O
Heart issues-angina pectoris, MI, pericarditis, dissecting AA
Lung issues-bronchitis, pneumonia
Chest Wall-costochondritis(mm), herpes (skin)
Esophagus-reflux dz, esophageal spasm
Neck-Cervical arthritis
GB-Radiating pain from biliary colic
Stomach-gastritis
Ask lots of questions...
Broad to specific
Ask the 7 attributes of the Sx when you find the pts sx/sxes. What are the 7 attributes of a Sx?
Location
Quality
Quantity/Severity (use scale here)
Timing
Setting in which it occurs
Remitting or exacerbating factors
Asso manifestations
Does lung tissue have pain fibers?
NO!!!!
Why do you get pain in lung conditions?
From inflammation of the adjacent parietal pleura (b/c of pulm infarction or pneumonia), a muscle strain, rib fractures and anxiety
What is the most common cause of chest pain in children?
ANXIETY!
Define dyspnea...
Nonpainful but uncomfortable awareness of breathing that is inappropriate to the level of physical exertion-mostly from cardiac or pulmonary disease
How do you assess the level of dyspnea?
Ask lots of questions!!!!!
Grade it...
Grading dyspnea...
Grade 0=not troubled by breathlessness except with strenuous exercise
Grade 1=troubled by SOB when hurrying on a level path or walking up a slight hill
Grade 2=Breathlessness when walking on a level path
Grade 3=stops to breath after walking about 100 yards on level path
Grade 4=too breathless to leave the house/breathless when changing
Coughing...from irritated receptors where?
Larynx
Trachea
Large Bronchi
What irritates these receptors?
mucus, pus, blood, dust, foreign bodies, hot or cold air, inflammation of mucosa, pressure or tension in the air passages, left-sided heart failure
Ask lots of questions...
dry or productive
describe phlegm or sputum
time
what helps it?
what makes it worse?
Dry hacking cough...
Mycoplasma pneumonia
Productive cough...
Bronchitis
Viral or bacterial pneumonia
Hemoptysis
Coughing up of blood from lungs. Blood-streaked phlegm or frank blood
In the young, Hemoptysis is seen most often with what?
cystic fibrosis
Ask lots of questions...
7 symptoms attributes
Is the bleeding actually coming from the lungs? If not, it's not hemoptysis
can come from mouth, pharynx, gi tract
If blood is coming from the stomach, how is it different than blood from the lungs?
Much darker and may be mixed with food particles
Can have a coffee ground look
OK-so all that was from packets of notes he has given us...NOW,
the following is from the packet, "Examination of Lung/Thorax"
This is more of what is needed for the practical...much of what he covered in this packet is on the previous cards!!!
Why would the trachea, upon inspection, be displaced laterally?
Pleural effusion
Pneumothorax
Atelectasis (collapsed)
What is the NL Chest depth to width ratio?
depth is 1/2 the width
Examination of...
...Posterior Chest
Inspection
I
I
Watch thorax from behind
What are you noting?
Shape of chest
How it moves with inspiration and expiration
Masses
Bruises
Lesions
Scars
Sinus Tracts
Retractions of Intercostals spaces-esp lower
When do you see retraction with inspiration?
Severe asthsma
COPD
Upper airway obstruction
Palpating
Posterior Chest
3 areas to focus on for Palpating the chest
Areas of tenderness and abnormalities in the overlying skin
Respiratory Expansion
Tactile Fremitus
Areas of tenderness and abnormalities in the overlying skin
Intercostal tenderness over inflamed area
Bruises over fractured ribs
Sinus Tracts
Excursion
Tests Chest Expansion
See cards at the beginning...went over this
What are the causes of unilateral decrease or delay in chest expansion?
Chronic fibrotic dz of underlying lung or pleura
Pleural effusion
Lobar pneumonia
Pleural pain asso w/splinting
Unilateral bronchial obstruction
Tactile Fremitus
Palpable vibrations caused by the transmission of air through the bronchopulmonary tree to the chest wall when the pt speaks
Tactile Fremitus is most helpful for detecting what?
Consolidation
Increased Tactile Fremitus is what?
Increased ratio of lung tissue or solid matter to air, decreased distance between lung and chest wall
Increased Tactile Fremitus is seen in what?
Pneumonia w/consolidation
Atelectasis
Lung tumors
Pulmonary Infarct
Pulmonary/Cystic Fibrosis
Bronchiectasis
Increase secretions in large airways
Decreased Tactile Fremitus is what?
Decreased ratio of lung tissue or solid matter to air, increased distance btwn lung and chest wall
Decreased Tactile Fremitus is seen in what?
Pneumothorax w/Lung Collapse
Pleural Effusion
Tumors in pleural space
Pleural thickening
Bronchial Obstruction
Asthma
Emphysema
Percussion
Posterior chest
Percussion
Helps to identify whether the underlying tissue is air, fluid or solid-filled
Resonant Sound
NL Lung
Flat Sound
(Like over thigh)
Large Pleural Effusion
Dull Sound
(Like over liver)
When fluid or solid tissue replaces air-filled lung or occupies pleural space
Lobar pneumonia
Pleural Effusion
Hemothorax
Pus
Tumor
Fibrous Tissue
Hyperresonance Sound
Emphysema
Pneumothorax
Tympany Sound
Large Pneumothorax
Auscultation
Posterior Chest
What do you do if abnormalities are suspected upon auscultation?
Listen to the sounds of the pt's spoken or whispered voice
What part of stethoscope do you use for breath sounds?
Diaphragm
How long do you listen to at each location?
Listen to at least 1 full breath
Where are the breath sounds going to be loudest?
In the lower posterior lung fields
Is inspiration longer or expiration?
Inspiration
Are breath sounds increased or decreased when NL lung is displaced by air or fluid?
Decreased
What do vesicular breath sounds switch to when there is fluid in the lung itself?
Bronchial Breath Sounds
When do you test a pt for Transmitted Voice Sounds?
When ABNL bronchovesicular or bronchial breath sounds are heard
Vocal Resonance
Male speech notes = 130 Hz
Female = 230 Hz
Overtones = 400-3500 Hz
Vowel sounds are produced by pairs of high frequency overtones and can be heard upon auscultation as indistinct sounds b/c the NL lung acts as a filter
If fluid or solid matter occupies the lung then the vowel sound becomes more distinct
A NL lung also filters out the voice sounds of spoken words or whispered words. Spoken words are muffled and whispered words cannot be heard.
In fluid or solid filled lungs, spoken words become more clear and whispered words are audible
There are 3 types of voice resonance
Bronchophony
Whispered Pectoriloquy
Egophony
Bronchophony
"Bronchus Sound" as would be heard over pt's bronchus
Negative Bronchophony = NL
Sounds will be muffled and indistinct
What would a positive Bronchophony (or ABNL) sound like?
Louder, Clearer
When would you find a positive finding?
Pulmonary Consolidation
Pulmonary Edema
Hemorrhage
Bronchophony is a sign of what?
Unfiltered transmission of breath sounds through consolidated or compressed lung tissue
When saying ninety-nine = clear and audible sounds then bronchophony is present.
= problem
Whispered Pectoriloquy
Whisper ninety-nine or one, two, three
Positive = ABNL
Whispering becomes audible
Negative = NL
Cannot hear the whispering
What does Whisper Pectoriloquy indicate?
Early pneumonia
Infarction
Pulmonary atlectasis
Egophony
Goat sound b/c has bleating quality
Occurs when high frequency sounds (vowels) are not filtered out but instead are enhanced
Positive Auscultation = ABNL
EEEE sounds like Ay
Negative Finding
EEE sounds like EEE...muffled
What does Egophony indicate?
Pleural effusion
Pulmonary consolidation
With all 3 vocal resonance tests, what does he say you must do?
Auscultate each bronchopulmonary segment
Inspection
Anterior Exam
See beginning of cards
...
Palpation
Anterior Exam
Same as posterior
...
Percussion
Anterior Exam
Same as Posterior
...
With percussion, where does the heart produce an area of dullness on the left side?
From the 3rd to the 5th intercostal spaces
You can percuss the left lung lateral to this dullness
Down left side = what?
Tympani of stomach
Down right side = what?
Dullness of liver
Auscultation
Anterior Exam
Same as posterior
...
See pages 8 & 9
for Misc Lung Exam Procedures