H&p Exam 2 Pulmonary Exam

Front 1

Name the important anatomy for the anterior thorax

Back 1

Manubrium, sternum, xiphoid process, costal cartilage, paired ribs, thoracic vertebrae

Front 2

Where would you insert a needle for a tension pneumothorax

Back 2

2nd intercostal space

Front 3

Where would you insert a chest tube

Back 3

4th intercostal space

Front 4

Lower margin of endotracheal tube on chest xray would be found where

Back 4

T4

Front 5

What is the last rib attached to the sternum

Back 5

7th rib

Front 6

What are the landmarks for thoracentesis

Back 6

T7-8

Front 7

What are the Anterior thorax anatomical landmarks

Back 7

Midsternal line (on the sternum), Midclavicular line (drops down from the middle of the clavicle), Anterior axillary line (distal end of the clavicle drops down)

Front 8

What are the axillary anatomical landmarks

Back 8

Anterior axillary line( drops down from the distal end of the clavicle or found at the anterior axillary fold), Midaxillary line (Drops from the apex of the axilla), Posterior axillary line (drops from the posterior axillary fold)

Front 9

What are the Posterior thorax anatomical landmarks

Back 9

Vertebral line (overlies the spinous process of the vertebrae), Scapular line (drops from the inferior angle of the scapula)

Front 10

Describe the components of the Right Lung

Back 10

Three lobes- Upper, Middle, Lower
Two Fissures- Horizontal (divides RUL &RML) Oblique (divides RML & RLL, and divides RLL & RUL)

Front 11

Describe the Left Lung

Back 11

Made up of two lobes upper and lower divided by an oblique fissure

Front 12

Where are the apices of the lungs located

Back 12

Extend above the clavicles

Front 13

Where can you find the base of the lungs

Back 13

The descend to the 6th rib of the mid clavicular line
The 8th rib at the midaxillary line
T-10 on the posterior

Front 14

Where does the trachea bifurcate into its main-stem bronchi

Back 14

At the level of the sternal angle anteriorly
And the T4 spinous process posteriorly

Front 15

What type of pleura covers the surface of the lung

Back 15

Visceral Pleura

Front 16

What type of pleura lines the inner rib cage and upper surfaces of the diaphragm

Back 16

Parietal Pleura

Front 17

What is the potential space between the visceral and parietal pleurae

Back 17

Parietal/pleural space

Front 18

Where is breathing controlled

Back 18

In the brainstem and mediated by muscles of inspiration

Front 19

What is the primary muscle of breathing

Back 19

Diaphragm

Front 20

What happens when the diaphragm contracts downward

Back 20

Descends the chest and enlarges the thoracic cavity decreasing thoracic pressure allowing air to be drawn through the tracheobronchial tree into the alveoli expanding the lungs.

Front 21

Describe the expiratory phase

Back 21

Passive process occurs when the diaphragm relaxes and rises allowing airflow outward and chest and abdomen to return to resting position

Front 22

What are the accessory muscles of respiration

Back 22

Sternomastoids (most important) scalenes, and abdominals assist with expiration

Front 23

Pain in the myocardium is associated with what

Back 23

Angina pectoris, myocardial Infarction

Front 24

Pain in the pericardium is associated with what

Back 24

pericarditis

Front 25

Pain in the aorta is associated with what

Back 25

dissecting aortic aneurysm

Front 26

Pain in the trachea and large bronchi is associated with what

Back 26

Bronchitis

Front 27

Pain in the parietal pleura is associated with what

Back 27

Pericarditis, pneumonia

Front 28

Pain in the Chest wall, including the musculoskeletal system and skin include what

Back 28

costochondritis, herpes zoster

Front 29

Pain in the esophagus is associated with what

Back 29

Reflux esophagitis, esophageal spasm

Front 30

Pain in the extrathoracic structures such as the neck, gallbladder, and stomach is associated with what

Back 30

Cervical arthritis, biliary colic, gastritis

Front 31

A clenched fist over the sternum suggests what

Back 31

angina pectoris

Front 32

a finger pointing to a tender area on the chest wall suggests this

Back 32

musculoskeletal pain

Front 33

A hand moving from the neck to epigastrum suggests this

Back 33

heartburn

Front 34

What is the most frequent cause of chest pain in children

Back 34

Anxiety, costochondritis is also common

Front 35

Anxious patients have have episodes of this during both rest and exercise

Back 35

hyperventillation, rapid or shallow breathing, frequent sigh

Front 36

What does wheezing suggest

Back 36

Partial airway obstructions from secretions, tissue inflammation, or foreign body

Front 37

This can be a symptom of Left Heart Failure

Back 37

Coughing

Front 38

This is the most common cause for acute cough

Back 38

Viral upper respiratory infections

Front 39

Describe mucoid sputum

Back 39

translucent, white or gray

Front 40

Describe purulent sputum

Back 40

yellowish greenish

Front 41

Foul smelling sputum is commonly found due to this

Back 41

lung abscess

Front 42

Tenacious sputum is usually a result of this

Back 42

cystic fibrosis

Front 43

Large volumes of purulent sputum is found as a result of this

Back 43

bronchiectasis or lung abscess

Front 44

What are some diagnostically helpful symptoms

Back 44

Fever, chest pain, dyspnea, orthopnea, and wheezing

Front 45

This is rare in infants, children, and adolescents

Back 45

hemoptysis

Front 46

This is commonly seen in patients with Cystic fibrosis

Back 46

Hemoptysis

Front 47

Describe blood which originates in the stomach

Back 47

usually darker than blood from the respiratory tract and can be mixed with food

Front 48

What are the main things to observe while inspecting your patient during the pulmonary exam

Back 48

Respiratory rate
Respiratory effort (full/shallow/labored)
Trauma
Deformity
Asymmetry
Symmetry of respirations

Front 49

Cyanosis is a signal for what

Back 49

hypoxia

Front 50

Clubbing can result from what

Back 50

lung abscess, malignancy, congenital heart disease

Front 51

Audible stridor and a high pitches wheeze is a sign of what

Back 51

Airway obstruction in the larynx or trachea

Front 52

Lateral displacement of the trachea occurs when

Back 52

Pneumothorax, pleural effusion, or atelectasis

Front 53

What is a sign of sever difficulty breathing

Back 53

inspiratory contractions of the sternomastoids and scalenes at rest

Front 54

What would cause the anteroposterior (AP) diameter to increase

Back 54

COPD, aging

Front 55

What can cause abnormal retractions during inspiration

Back 55

severe asthma, COPD, and upper airway obstruction

Front 56

What does unilateral impairment or lagging of respiratory movements suggest

Back 56

Disease of the underlying lung pleura

Front 57

What does intercostal tenderness usually imply

Back 57

inflamed pleura

Front 58

What do sinus tracts indicate

Back 58

infection of the underlying pleura and lung as in tuberculosis and actinomycosis

Front 59

What are the causes for unilateral decreased delay in chest expansion

Back 59

Chronic fibrosis of the underlying lung pleura, pleural effusion, labor pneumonia, pleural pain associated with splinting, and unilateral bronchial expansion

Front 60

What are some causes for decreased Fremitus

Back 60

Thick chest wall, obstructed bronchus, COPD, Pleural effusion, fibrosis, pneumothorax, infiltrating tumor

Front 61

What are the causes of asymmetric decreased fremitus

Back 61

unilateral pleural effusion, pneumothorax, and neoplasm

Front 62

What are the causes of asymmetric increased fremitus

Back 62

unilateral pneumonia

Front 63

When does dullness replace resonance

Back 63

when fluid or solid tissue replaces air-containing lung or occupies pleural space

Front 64

What are some examples of dullness replacing resonance

Back 64

labor pneumonia, pleural effusion, hemothorax, empyema, fibrous tissue, tumor

Front 65

When can Generalized resonance be heard

Back 65

over the hyperinflated lungs of COPD (not a reliable sign)

Front 66

What does unilateral hyperresonance suggest

Back 66

Large pneumothorax or a large air-filled bulla in the lung

Front 67

When percussing the diaphragm an abnormally high level indicates what

Back 67

pleural effusion, or a high diaphragm which can occur due to atelectasis or diaphragmatic paralysis

Front 68

When can breath sounds be decreased

Back 68

when air flow is decreased as in obstructive lung disease, or muscular weakness

Front 69

What can cause poor sound transmission when auscultation the lungs

Back 69

pleural effusion, pneumothorax, COPD

Front 70

Describe Vesicular breath sounds

Back 70

inspiratory sounds last longer than expiratory
Soft low pitched
found over majority of lungs

Front 71

Describe bronchovesicular lung sounds

Back 71

Inspiratory and expiratory sounds are equal

found in the 1st and 2nd interspaces anteriorly and between the scapulae

Front 72

Describe Bronchial breath sounds

Back 72

Expiratory sounds last longer than inspiratory
Loud intensity with high pitch
Found over the menubrium if heard at all

Front 73

Describe tracheal breath sounds

Back 73

inspiratory and expiratory sounds are equal
loud intensity high pitch
Found over the trachea and neck

Front 74

What would cause bronchovesicular or bronchial breath sounds to be heard in abnormal locations

Back 74

Occurs when air filled lung is replaced with fluid filled or solid tissue

Front 75

What a silent gap between inspiration and expiration breath sounds suggest

Back 75

bronchial breath sounds

Front 76

What is a sign of abnormal lung tissue

Back 76

Fine late inspiratory crackles that persist from breath to breath

Front 77

When does dullness replace resonance when percussing the chest

Back 77

When fluid or solid tissue replaces air containing lung or pleural space

Front 78

Hyperresonance of this disease may totally replace cardiac dullness

Back 78

COPD

Front 79

Where does the dullness of right middle lobe pneumonia typically occur

Back 79

behind the right breast this is why you must displace the breast when you percuss

Front 80

A lung affected by COPD often has this result on the liver

Back 80

displaces the upper border of the liver downward as a result lowering the level of diaphragmatic dullness posteriorly

Front 81

Patients older than 60 years with a forced expiratory time of 6-8 sec are twice as likely to have what disease

Back 81

COPD

Front 82

An increase in the local pain (distant from your hands) suggests this

Back 82

rib fracture rather than just soft tissue injury

Front 83

Describe a normal thorax

Back 83

wider than deep, lateral diameter is larger than its anteroposterior

Front 84

Describe a Funnel chest (pectus excavatum)

Back 84

Depression in the lower portion of the sternum
Compression of the heart and great vessels can cause murmurs

Front 85

Describe Barrel Chest

Back 85

Increased anteroposterior diameter

Front 86

Pigeon Chest (Pectus carinatum)

Back 86

Sternum is displaced anteriorly, increasing the anteroposterior diameter
costal cartilages adjacent to the protruding sternum are displaced

Front 87

Describe traumatic flail chest

Back 87

multiple rib fractures result in paradoxical movements of the thorax
inspiration the injured area caves inward on expiration it moves outward

Front 88

Describe thoracic kyphoscoliosis

Back 88

abnormal spinal curvatures and vertebral rotations deform the chest can make lung findings very difficult

Front 89

Describe the breath sounds in normal air filled lungs

Back 89

Predominantly vesicular

Front 90

Describe transmitted voice sounds in normal air filled lungs

Back 90

muffled indistinct, spoken ee heard as ee whispered words are faint, indistinct if heard at all

Front 91

Describe tactile fremitus in normal lungs

Back 91

normal

Front 92

describe tactile fremitus in airless lungs as in lobar pneumonia

Back 92

increased

Front 93

Describe transmitted voice sounds in airless lungs as in lobar pneumonia

Back 93

spoken words are louder, clearer. spoken ee heard as ayy.
whispered words are louder, clearer,

Front 94

Describe breath sounds in a airless lung as in lobar pneumonia

Back 94

bronchial or bronchialvesicular over the involved area

Front 95

Describe late inspiratory crackles

Back 95

begin in the first half of inspiration and are continue into late inspiration
appear first at the base of the lung and spread upward as the condition worsens and shift to dependent regions with changes in posture

Front 96

What are the causes of late inspiratory crackles

Back 96

interstitial lung disease (fibrosis), early CHF

Front 97

Describe early inspiratory crackles

Back 97

appear and end soon after the start of inspiration
coarse and few in number
expiratory crackles are sometimes associated

Front 98

What are the causes of early inspiratory crackles

Back 98

chronic bronchitis and asthma

Front 99

When are mid inspiratory and expiratory crackles heard

Back 99

bronchiectasis but not specific for diagnosis. Can be associated with wheezing and rhonchi

Front 100

When do wheezes occur

Back 100

when air flows rapidly through bronchi that are narrowed nearly to the point of closure. Often are audible through the mouth and chest.

Front 101

What are the causes of wheezing

Back 101

Asthma, COPD, chronic Bronchitis, CHF

Front 102

What do rhonchi suggest

Back 102

secretions in the larger airways and can be cleared with coughing in diseases such as chronic bronchitis

Front 103

In sever obstructive pulmonary disease what does silent chest mean

Back 103

Pt is unable to force enough air through the narrowed bronchi to produce wheezing this warrants immediate attention

Front 104

What does persistent localized wheezing suggest

Back 104

partial obstruction of the bronchus by a tumor or foreign body

Front 105

What is a wheeze that is predominantly inspiratory called

Back 105

stridor. Often louder in the neck than the chest wall. This indicates a partial obstruction of the larynx or trachea and is a medical emergency

Front 106

Creaking sounds that occur when pleural surfaces are inflammed and roughened

Back 106

pleural rub
can resemble crackles but usually located in a confined small area and is heard in both phases of respiration

Front 107

This is a series of precordial crackles synchronous with the heart beat not with respiration. Best heard in the left lateral position and is due to mediastinal emphysema

Back 107

Mediastinal crunch

Front 108

What are some evidence of distress

Back 108

tripoding, pursed lip breathing, central cyanosis, accessory muscle use, retractions

Front 109

Percussion helps to determine what

Back 109

air filled lungs vs fluid filled or solid mass

Front 110

When percussing during the pulmonary exam Resonance means what

Back 110

healthy aerated lungs loud intensity

Front 111

When percussing during the pulmonary exam hyperresonance means what

Back 111

air trapping, very loud intensity

Front 112

When percussing during the pulmonary exam hyporesonance sounds like what

Back 112

dull/flat lower intensity

Front 113

When would you perform diaphragmatic excursion

Back 113

respiratory expansion is asymmetrical, abnormal percussion notes, adventitious breath sounds

Front 114

Describe a normal diaphragmatic excursion

Back 114

Resonance above the level of the diaphragm
Dull below the level of the diaphragm
expect excursion 5-6cm

Front 115

This adventitious sound is intermittent, brief, nonmusical and is more fine than course

Back 115

Crackle (rales)

Front 116

This adventitious sound is continuous, musical, and high pitched

Back 116

Wheezes

Front 117

This adventitious breath sound is continuous, snoring quality, and low pitched

Back 117

Rhonchi

Front 118

This test is performed if crackles are appreciated

Back 118

Post tussive check

Front 119

This test involves the patient saying EE during auscultation and if abnormal will sound like AYY

Back 119

egophony

Front 120

This test involves the pt whispering 123 during auscultation if abnormal the sounds will be loud and clear as a result of consolidation

Back 120

whispered pectoriloquy