Pcs Chs 5 &6

Front 1

What is the palpebral fissure?

Back 1

Area between the opening of the eyelids.

Front 2

What are tarsal plates?

Back 2

CT w/in eyelids-->each plate has parallel row of meibomian glands, which open on lid margin.

Front 3

What is responsible for raising the upper eyelid & what is its innervation?

Back 3

1. Levator palpebrae muscle: by CNIII
2. Smooth muscle innervated by sympathetic nervous system assists.

Front 4

What are the three sources of tear fluid and what is its function?

Back 4

Fxn: protects conjunctiva & cornea from drying, inhibits microbial growth, gives smooth optical surface to cornea.
Sources of fluid: meibomian glands, conjunctival glands, lacrimal gland.

Front 5

What do the muscles on the iris do? What do muscles of ciliary body to?

Back 5

Iris muscles-->control pupillary size.
Ciliary body muscles-->control lens thickness, lets eye focus on distant objects.

Front 6

What is the pathway of tears within the eye?

Back 6

Lacrimal gland (above & lateral to eye)-->fluids speads across eye & drains medially into 2 tiny holes called lacrimal puncta-->lacrimal sac-->& into nose thru nasolacrimal duct.

Front 7

Describe the circulation path of the aqueous humor and its fxn.

Back 7

Fxn: to control P inside eye.
Aqueous humor produced by ciliary body in posterior chamber-->thru pupil to anterior chamber-->drains out thru Canal of Schlemm

Front 8

What is the fxn of the vitrous body?

Back 8

Its a transparent mass of gelatinous material that fills eyeball behind lens. It helps to maintain SHAPE of lens.

Front 9

Why and where do we have a blind spot?

Back 9

B/c of lack of retinal receptors at optic disc, oval blind spot in normal field of each eye, 15 degrees temporal to line of gaze

Front 10

Which CN mediates the near reaction?

Back 10

Oculomotor N

Front 11

What is the pathway of the sympathetic fibers to the eye?

Back 11

Starts in hypothalamus & passes down thru brainstem & cervical cord into neck. From there, it follows carotid A or its branches into orbit. Lesion anywhere on this pathway may impair sympathetic effects on pupil.

Front 12

What are the compartments of the ear?

Back 12

external ear (auricle & ear canal thru tympanic membrane), middle ear (ossicles: malleus, incus, stapes), inner ear

Front 13

Are you able to directly examine the inner ear?

Back 13

No, you can't directly examine the inner or ,ost of external ear, but you can make inferences based on tests of auditory fxn.

Front 14

Describe the pathway of hearing.

Back 14

Vibrations thru external ear, transmitted thru eardrum & ossicles of middle ear to cochlea (pt of inner ear)-->cochlea senses vibrations-->N impulses sent to brain thru cochlear N.

Front 15

What is conductive hearing loss?

Back 15

A disorder in the conductive phase of hearing, so from external ear to middle ear.

Front 16

How does one get sensorineural hearing loss?

Back 16

Involves 2nd pt of pathway: Cochlea & cochlear N.;

Front 17

The __________ w/in inner ear senses position & movements of head & helps to maintain balance.

Back 17

Labyrinth

Front 18

Which pathway is used for testing hearing loss?

Back 18

Bone conduction pathway which bypasses external & middle ear. Set tuning fork on bone w/ vibration, & this vibration will stimulate cochlea directly.

Front 19

In normal hearing person, which is more sensitive: air conduction or bone conduction?

Back 19

Air conduction

Front 20

Which part of the nasal cavity is covered with hair-bearing skin rather than mucosa, unlike the rest of the nasal cavity?

Back 20

Vestibule

Front 21

What are the curving bony structures covered by highly vascular mucous membranes that protrude into nasal cavity?

Back 21

Turbinates

Front 22

What can be seen on examination of the nasal cavity thru the anterior naris?

Back 22

Vestibule, anterior pt of septum, lower & middle turbinates.

Front 23

A tooth is composed mainly of ______.

Back 23

dentin

Front 24

What structure connects the tongue to the floor of the mouth?

Back 24

Lingual frenulum

Front 25

Where does each parotid gland empty in the mouth?

Back 25

near the upper 2nd molar--Stensen's duct.

Front 26

What are the submandibular gland ducts called that open on papillae that lie on each side of lingual frenulum?

Back 26

Wharton's ducts.

Front 27

The neck is divided into 2 triangles by the sternomastoid muscle. What are the borders of the 2 triangles?

Back 27

Anterior triangle bounded by mandible above, laterally by sternomastoid, medially by midline of neck. Posterior triangle: clavicle below, sternomastoid to trapezius.

Front 28

What vessels line deep to sternomastoid?

Back 28

Carotid artery & internal jugular vein. External jugular vein passes diagonally over surface of sternomastoid.

Front 29

Lists the lymph nodes of the head & neck region.

Back 29

Preauricular, posterior auricular, occipital, tonsillar, superficial cervical, posterior cervical, supraclavicular, submental, submandibular, deep cervical chain.

Front 30

What happens to the tonsils & other lymphoid tissue with age?

Back 30

(composed of lymphoid tissue). After age 5, they get gradually smaller. In adults-->invisible. Frequency of palpable lymph nodes also dec with age.

Front 31

In contrast to the lymph nodes, what becomes easier to feel in older people?

Back 31

Submandibular glands

Front 32

How does vision change w/ age?

Back 32

-Visual acuity fairly constant b/w 20-50 & then diminishes until 70 & then more rapidly.
-Elderly-->near vision begins to become blurry for everyone
-From childhood on, lens gradually loses its elasticity & eye gets less able to focus on nearby objects=PRESBYOPIA (obvious in 40s)

Front 33

What happens to the tissues around the eyes w/ age?

Back 33

-Fat surrounding & cushioning eye atrophies-->eyeball recedes in orbit.
-skin of eyelid gets wrinkled
-fat may push fascia of eyelids forward, creating soft bulges.
-eyes produce fewer lacrimal secretions, so they have dry eyes.

Front 34

What happens to the eyeball w/ aging?

Back 34

-corneal arcus (arcus senilis) common in elderly, no clinical significance;
-corneas lose luster, pupils get smaller & irregular (but should still respond to light).
-lenses thicken & yellow, so hard to get passage of light into eye;
-cataracts are common (1:10 in 60s, 1:3 in 80s)
-Glaucoma: lens can push iris forward & narrow angle b/w iris & cornea and inc risk of narrow-angle glaucoma.
-arteries narrowed, paler, straigher, less brillian
-may see vitrous floaters
-macular degeneration, glaucoma, retinal hemorrhages, retinal detachment.

Front 35

Describe the types of hearing loss that occur w/ age.

Back 35

Early loss: start in young adulthood, involve high-pitched sounds beyond range of human speech, little fxn'al significance.
-PRESYCUSIS: hearing loss associated w/ aging, also involves middle & lower rangles, usually after 50 y/o

Front 36

What is the chief cause of tooth loss in adults?

Back 36

peridontal disease

Front 37

Overclosure of the mouth may lead to what?

Back 37

Maceration of the skin @ corners--angular cheilitis

Front 38

What are the common & concerning sx's of head & neck?

Back 38

HA, Change in vision (hyperopia, presbyopia, myopia, scotomas), double vision or diplopia, hearing loss, earache; tinnitus, vertigo, nosebleed (epistaxis), sore throat; hoarsness; swollen glands, goiter.

Front 39

What are the most important attributes of headache?

Back 39

chronologic pattern & severity.

Front 40

What are the most common kinds of recurring headaches?

Back 40

Tension & migrains headaches

Front 41

Tension HA's arise where?

Back 41

Temporal areas.

Front 42

Cluster headaches occur where?

Back 42

Retro-orbital

Front 43

Changing or progressively severe headaches inc the likelihood of what?

Back 43

Tumor, abscess, or other mass lesion.

Front 44

Extremely severe headaches suggest what?

Back 44

Subarachnoid hemorrhage or meningitis.

Front 45

Which condition has visual auras or scintillating scotomas?

Back 45

Migraines (fam hx may also be positive w/ migraines)

Front 46

N & V common w/ migraine, but occur with what other conditions?

Back 46

Brain tumors & subarachnoid hemorrhage.

Front 47

If coughing, sneezing, or changing head position have an effect on HA, what could this be a sign of?

Back 47

These maneuvers inc pain from brain tumor & acute sinusitis.

Front 48

How might high blood pressure affect vision?

Back 48

May cause blurring

Front 49

Refractive errors most commonly explain what?

Back 49

Gradual blurring

Front 50

Sudden visual loss suggests what?

Back 50

Retinal detachment, vitrous hemorrhage, or occlusion of central retinal artery.

Front 51

What is the difference b/w HYPEROPIA, PRESBYOPIA, and MYOPIA?

Back 51

Hyperopia: farsightedness, presbyopia:aging vision, myopia: difficulty: nearsightedness

Front 52

Slow central loss of vision occurs in which 2 conditions?

Back 52

Nuclear cataract & macular degeneration

Front 53

Peripheral loss of vision occurs in which 2 conditions?

Back 53

Advanced open-angle glaucoma

Front 54

One-sided loss of vision occurs in which conditions?

Back 54

Hemianopsia & quadrantic defects.

Front 55

Moving specks or strands in vision suggest what?

Back 55

Vitreous floaters

Front 56

Fixed defects (scotomas) suggest what?

Back 56

Lesions in retinas or visual pathways.

Front 57

Flashing lights across the visual field or new vitrous floaters suggest what?

Back 57

Detachment of vitreous from retina. Need prompt eye consultation!

Front 58

What are the causes of diplopia in adults?

Back 58

Lesion in brainstem or cerebellum, or from wkness or paralysis of one of more extraocular muscles as in horizontal diplopia from palsy of CN III or VI, or vertical diplopia from palsy of CN III or CN IV.

Front 59

Diplopia in 1 eye w/ the other closed suggests what?

Back 59

Problem in cornea or lens

Front 60

What is the difference b/w horizontal and vertical diplopia?

Back 60

Horizontal: 2 images side by side;
Vertical: 2 images on top of each other

Front 61

What are the symptoms of someone w/ sensorineural hearing loss?

Back 61

(problem in inner hear, cochlear nerve, or its central connection to brain);
Sx: trouble understanding speech, often complaining others mumble; noisy environments make hearing worse. In conductive hearing loss, noise environments HELP!

Front 62

What are some medications that affect hearing?

Back 62

Aminoglycosides, aspirin, NSAIDS, quinine, furosemide.

Front 63

What are some differences in sx's b/w otitis externa & otitis media?

Back 63

Pain in external ear=otitis externa.
If assoc w/ respiratory infection sx's in inner ear=otitis media.

Front 64

Acute or chronic otitis media causes from what type of discharge from the ear?

Back 64

Unusually soft wax, debris from inflammation or rash in ear canal, or discharge thru perforated eardrum secondary to acute or chronic otitis media.

Front 65

When tinnitus is associated w/ hearing loss & vertigo, it suggests what condition?

Back 65

Meniere's disease.

Front 66

Feeling unsteady, light-headed, or 'dizzy in the legs" sometimes suggest what?

Back 66

Cardiovascular etiology

Front 67

Feeling of being pulled suggests what?

Back 67

true vertigo from an inner ear problem or a central or peripheral lesion of CN VIII

Front 68

What are some causes of rhinorrhea?

Back 68

Viral infections, allergic rhinitis (hay fever), & vasomotor rhinitis. Excessive decongestant use may worsen sx's.

Front 69

What are some symptoms of allergies?

Back 69

Rhinorrhea w/ itching in eyes, nose, throat. Relation to season and environment.

Front 70

What drugs may cause stuffiness?

Back 70

oral contraceptives, reserpine, guanethidine, & alcohol

Front 71

Rhinorrhea, congestion, w/ pain & tenderness in face or over sinuses, local HA, or fever suggest what?

Back 71

Sinusitis

Front 72

If nasal congestion is limited to one side, what should you think of?

Back 72

Deviated nasal septum, foreign body, tumor.

Front 73

What are some local causes of epistaxis?

Back 73

Trauma (esp nose picking), inflammation, drying & crusting of nasal mucosa, tumors, & foreign bodes. Bleeding d/o's contribute to epistaxis.

Front 74

What are the sx's of streptococcal pharyngitis or strep throat?

Back 74

fever, pharyngeal exudates, anterior lymphadenopathy, esp w/o cough

Front 75

Sore smooth tongue indicates what?

Back 75

Nutritional deficiency

Front 76

Bleeding gums are most often caused by what?

Back 76

Gingivitis

Front 77

What are the most common causes of hoarseness?

Back 77

overuse of voice, acute infections, allergy, smoking, or other inhaled irritants; If > 2wks, need indirect or directly laryngoscopy.

Front 78

What are some sx's of hypothyroidism?

Back 78

intolerance to cold, preference for warm clothing, decreased sweating, coarse hair, lateral sparseness of eyebrows

Front 79

What are some sx's of hyperthyroidism?

Back 79

palpitations, involuntary weight loss, fine hair, poor convergencce, lid lag

Front 80

What are some impt topics for health promotion & counseling in head & neck?

Back 80

-changes in vision: cataracts, macular degeneration, glaucoma;
-hearing loss
-oral health

Front 81

What is the leading cause of blindness in African Americans & second leading cause of blindness overall?

Back 81

Glaucoma (gradual loss of vision w/ damage to optic N, loss of visual fields beginning in periphery, & pallor & inc size of optic cup (enlarges to more than 1/2 of optic cup). Elevated IOP in 80% of cases)

Front 82

What are the risk factors of glaucoma?

Back 82

>65, African American, DM, myopia, family hx of glaucoma, ocular hypertension.

Front 83

What are some risk factors for hearing loss?

Back 83

hx of congenital or familial hearing loss, syphilis, rubella, meningitis, exposure to hazardous noise levels.

Front 84

What 2 conditions give you an enlarged skull?

Back 84

hydrocephalus & Paget's dz of bone

Front 85

What does vision of 20/200 mean?

Back 85

@ 20 feet person can read print that a pt w/ nl vision could read at 200 feet. The larger the second number, the worse the vision.

Front 86

When is a person considered legally blind?

Back 86

20/200. Legal blindness also results from constricted field of vision: 20 degrees or less in better eye.

Front 87

How far do you use a hand-held Snellen eye chart?

Back 87

14 inches.

Front 88

You get an enlarged blind spot in which conditions?

Back 88

Those affecting the optic N like glaucoma, optic neuritis, papilledema

Front 89

What test result would make a patient positive for a left temporal hemianopsia?

Back 89

When w/ peripheral vision test, if patient's left eye repeatedly doesn't see your fingers until they've crossed line of gaze.

Front 90

When do you have abnormal protrusion of eyes?

Back 90

Graves disease or ocular tumors

Front 91

What is Blepharitis?

Back 91

inflammation of eyelids along lid margins, often w/ crusting or scales.

Front 92

Scaliness of skin under eyebrows is with which condition?

Back 92

Seborrheic dermatitis

Front 93

What are the causes of excessive tearing?

Back 93

May be due to increased production (causes: conjunctival inflammation & corneal irritation) or impaired drainage of tears (nasolacrimal duct obstruction).

Front 94

What is the most common type of glaucoma?

Back 94

Narrow-angle glaucoma-->sudden inc in intraocular P when drainage of aqueous humor is blocked.

Front 95

When is anisocoria considered benign?

Back 95

If pupillary rxns are normal

Front 96

When should you pause when doing the H to check for nystagmus?

Back 96

when upward & lateral

Front 97

What are contraindications for using mydriatic eye drops?

Back 97

1)head injury & coma, in which continuing observations of pupillary rxns are essential.
2) any suspicion of narrow-angle glaucoma.

Front 98

Which hand should you be holding the opthalmoscope with to check each eye?

Back 98

Right hand w/ right eye and vice versa.

Front 99

What is the red reflex?

Back 99

When you shine the light on the pupil and get an orange glow in the pupil--you want to note any opacities interrupting red reflex

Front 100

What is hippus?

Back 100

spasm of pupil--may be from brightness of light in their eye

Front 101

Absence of red reflex suggests what?

Back 101

Opacity of lens (cataract) or possibly of vitreous. Less commonly, a detached retina, or in kids, a retinoblastoma may obscure this reflex. Don't be fooled by artificial eye, which has no red reflex!!!

Front 102

An enlarged physiologic cup suggests what?

Back 102

chronic open angle glaucoma

Front 103

Loss of venous pulsations is in what pathologic conditions?

Back 103

Head trauma, meningitis, or mass lesions-->early sign of inc ICP

Front 104

What are the 2 types of macular degeneration (big cause of poor central vision in elderly)?

Back 104

Dry atrophic (more common but less severe) & wet exudative (neovascular)

Front 105

'tug test' of auricle painful in which condition?

Back 105

Acute otitis externa (inflammation of ear canal--swollen, narrow, moist, pale, tender, reddened, canal) NOT otitis media (inflammation of middle ear-->but have tenderness BEHIND ear)

Front 106

What are exostoses?

Back 106

Nontender nodular swellings covered by nl skin deep in ear canals; nonmalignant overgrowths which may obscure ear drum.

Front 107

What does the ear canal look like chronic otitis externa?

Back 107

Skin of canal is thickened, red, itchy.

Front 108

What does a red bulging ear drum indicate? Amber drum?

Back 108

Perulent otitis media, serous effusion.

Front 109

What does an unusually prominent short process & prominent handle of malleus that looks more horizontal indicate?

Back 109

Retracted ear drum

Front 110

What are some causes of unilateral conductive hearing loss (w/ Weber's test-->sound heard in impaired ear)?

Back 110

acute otitis media, perforation of eardrum, obstruction of ear canal by cerumen.

Front 111

In unilateral sensorineural hearing loss, where is sound heard?

Back 111

Good ear

Front 112

How does the nasal mucosa look difference in viral and allergic rhinitis?

Back 112

Viral rhinitis: mucosa reddened & swollen;
Allergic rhinitis: pale, bluish, red.

Front 113

What are some causes of septal perforation?

Back 113

Intranasal use of cocaine (can also lead to nasal ulcers) & amphetamines.

Front 114

What's the test for CN XIII

Back 114

stick out your tongue (lesion if asymmetric)

Front 115

Whats the 2nd most common cause of cancer of the mouth (after lips)?

Back 115

tongue, usually on side (esp w/ tobacco, alcohol)

Front 116

What happens in CN X paralysis?

Back 116

open mouth, soft palate fails to rise & uvula deviates to OPPOSITE side

Front 117

Tender lymph nodes suggest what? Hard/fixed nodes suggest what?

Back 117

Inflammation; Malignancy

Front 118

How can you notice masses in neck?

Back 118

May push trachea to 1 side; can also show impt problems in thorax like mass, atelectasis, or lg pneumothorax.

Front 119

Where is the angle of louis or sternal angle?

Back 119

Adjacent to 2nd rib & costal cartilage.

Front 120

Which ribs articular w/ costal cartilages?

Back 120

1-7

Front 121

Inferior tip of scapula lies @ which rib level?

Back 121

7th rib or interspace

Front 122

Lower border of lung lies @ which level?

Back 122

T10

Front 123

What are the fissures of the R lung?

Back 123

Major (oblique) and minor (horizontal) fissure

Front 124

Signs in the R middle lung field laterally are from what pt of lung?

Back 124

Any of three lobes

Front 125

Signs in R upper lung field are from what area?

Back 125

R upper area

Front 126

Where does the trachea bifurcate?

Back 126

sternal angle anteriorly; T4 posteriorly;

Front 127

What are visceral & parietal pleurae?

Back 127

-Visceral pleurae are serous membranes that cover outer surface of each lung;
-Parietal pleura line inner rib cage & upper surfaces of diaphragm

Front 128

What is pleural space?

Back 128

Potential space b/w visceral & parietal pleura

Front 129

What is the primary muscle of inspiration?

Back 129

Diaphragm (w/ contraction, it descends)

Front 130

In ______ position, mvmts of thorax become more prominent.

Back 130

Seated

Front 131

What are the accessory muscles of inspiration>

Back 131

Most impt: sternomastoids;
scalenes; Abdominal muscles w/ expiration

Front 132

What are the common or concerning sx's of thorax & lungs?

Back 132

chest pain, dyspnea, wheezing, cough, blood-streaked sputum (hemoptysis)

Front 133

What are the changes of thorax & lungs w/ aging process?

Back 133

dec capacity for exercise, chest wall stiffer, harder to move, respiratory muscles weakens, lungs lose some elastic recoil, speed of breathing out w/ max effort dec, skeletal changes-->kyphosis, inc anteroposterior diameter of chest-->barrel chest.

Front 134

A clenched fist over sternum suggest what?

Back 134

Angina pectoris

Front 135

A finger pointing to a tender area on chest wall suggests what?

Back 135

musculoskeletal pain

Front 136

A hand moving from neck to epigatrum suggests what?

Back 136

heartburn

Front 137

Whats the most frequent cause of chest pain in kids?

Back 137

Anxiety, constochonrditis also common

Front 138

Does lung tissue have pain fibers? How do we sense pain in chest?

Back 138

Lung tissue has NO pain fibers. Pain in lung conditions like pneumonia or pulm infarction arises from adjacent parietal pleura. May also be from muscle strain from prolonged recurrent coughing.

Front 139

Define dyspnea

Back 139

Nonpainful but uncomfortable awareness of breathe thats inappropriate to level of exertion

Front 140

Since you can't really quantify dyspnea, whats the best way to determine severity?

Back 140

Based it on pt's daily activities.

Front 141

Wheezing suggests what?

Back 141

partial airway obstruction from secretions, tissue inflammation, or foreign body

Front 142

What is an important sx of L-sided heart failure?

Back 142

cough

Front 143

Mycoplasmal pneumonia gives you what type of cough? Bronchitis, viral, bacterial pneumonia?

Back 143

dry hacking; productive cough;

Front 144

Mucoid sputum cs purulent sputum?

Back 144

Mucoid: translucent, white or gray; perulent: yellowish or greenish

Front 145

Sputum in CF?

Back 145

tenacious sputum; also hemoptysis;

Front 146

Sputum in anaerobic lung abscess?

Back 146

Foul-smelling

Front 147

How is hemoptysis different for blood originating from stomach vs/ respiratory tract?

Back 147

Stomach: darker & maybe mixed w/ food particles;

Front 148

Lg volumes of purulent sputum in which conditions?

Back 148

Bronchiectasis or lung abscess

Front 149

Whats the leading cause of preventable death?

Back 149

smoking

Front 150

What are the 4 A's of smoking cessation?

Back 150

-Ask about smoking @ each visit.
-Advise pts regularly to stop smoking in clear personalized message.
-Assist pts to set stop dates & provide educational materails for self-help.
-Arrange for follow-up visits to monitor & support progress

Front 151

What should be included in initial survey of respiration?

Back 151

Rate (14-20x/min), rhythm, depth, breathing effort

Front 152

What are signs of resp difficulty?

Back 152

Pts color for cyanosis (signals hypoxia, clubbing of nails in COPD or congenital heart disease, listen to breathing (stridor--high-pitched wheeze), inspiratory contraction of sternomastoids @ rest:severe difficulty breathing, lateral displacement of trachea in pneumothorax, pleural effusion, atelectasis), COPD-->AP diameter inc

Front 153

Unilateral impairment or lagging of respiratory mvmt suggests what?

Back 153

dz of underlying lung or pleura.

Front 154

When placing your hands @ level of 10th rib, whats the cause of unilateral dec or delay in chest expansion?

Back 154

Chronic fibrotic dz of underlying lung or pleura, pleural effusion, lobar pneumonia, pleural pain w/ associated splinting, and unilateral bronchial obstruction

Front 155

What are causes of dec or absent fremitus?

Back 155

obstructed bronchus, COPD, separation of pleural surfaces by fluid (pleural thickening), fibrosis (pleural thickening), air (pneumothorac), or an infiltrating tumor, very thick chest wall.

Front 156

Fremitus is more prominent in what region?

Back 156

Intrascapular region

Front 157

When does dullness replace resonance?

Back 157

When fluid or solid tissue replaces air-containing lung or occupies pleural space beneath percussing fibers. ex. lobar pneumonia

Front 158

Describe the characteristics of flatness.

Back 158

intensity: soft, pitch: high, duration: short, location: thigh;path: lg pleural effusion

Front 159

Describe dullness.

Back 159

intensity: medium; pitch: medium; duration: medium: location: liver; path: lobar pneumonia

Front 160

Describe resonance

Back 160

intensity: loud, pitch: low; duration: long; location: nl lung; path: simple chronic bronchitis

Front 161

Describe hyperresonance

Back 161

intensity: very loud, pitch: lower, duration: long, location: none normally; path: emphysema, pneumothorax

Front 162

Describe tympany.

Back 162

intensity: loud, pitch: high, location: gatric air bubble or puffed out cheek. path: large pneumothorax

Front 163

What are normal breath sounds?

Back 163

vesicular, bronchovesicular, bronchial

Front 164

What is the nl amt of diaphragmatic excursion?

Back 164

5-6 cm