Physical Assessment: Thorax & Lungs

Front 1

Anterior Thoracic Cage

Back 1

-suprasternal notch-U-shaped
-sternum-three parts:
-manubrium
-body
-xiphoid process
-manubriosternal angle (angle of Louis)-at 2 rib-landmark
-Ic space named for the # rib above it
-floor of cage=diaphragm

Front 2

Barrel Chested

Back 2

over inflated lungs

Front 3

Posterior Thoracic Cage

Back 3

-vertebra prominens (C7)
-see as most prominent bone when you bend down neck
-spinous processes
-inferior border ot scapula-usually at 7 or 8 rib
-inferior angle of scapula
-12th rib-midway btw spine and side--find location of free tip

Front 4

Anterior Reference Lines

Back 4

midsternal line-right down middle of sternum
-anterior axillary-start of axilla
-mid clavicular line-midway in clavicle

Front 5

Posterior Reference Lines

Back 5

-scapular line
-vertebral line

Front 6

Lateral Reference Lines

Back 6

-anterior axillary
-posterior axillary
-midaxillary

Front 7

Location of Lungs

Back 7

-right a little shorter than left
-b/c liver sits below
-right middle lobe-auscultate
-Base around 6th rib

On posterior side:
-deflated lung-be around T10
-inflated-T12

Front 8

Structure of Lungs

Back 8

3 parts:
1&2. right and left pleurae
-visceral continuous w parietal lining of chest wall
-parietal
-pleural cavity-fluid to help w movement
-fluid can accumulate in costodia
3. media stinum-esphagus, trachea, heart, branch vessel coming off and to heart (aorta)
-trachea-around 2nd rib
-right bronchial tree a little shorter and straighter than left
inhales-get caught there bc straighter angle to get there
alveoli-at end for ventillation

Front 9

Functions of ventilation

Back 9

-supply O2 to body for energy
-remove CO2 as waste
-maintain acid-base balances of arterial blood
-maintain heat exchange

Front 10

Mechanics of Ventilation

Back 10

-change chest size
-chest size decreases and recoils-->air expelled
-chest size increases and expands-->air comes in
-diaphragm contracts and pushes down on liver, spleen, abdominal contents
-inhale to examen size of contents

Front 11

Inspection of Chest wall

Back 11

Ratio of anteriorpost:transverse diameter
=1:2
length across chest 2x width
-costal angle should be less than 90

Front 12

Bradypnea

Back 12

-less than 10 breaths/min
-deep
-caused by intercranial pressure or meds

Front 13

Hyperventillation

Back 13

-deep and rapid ventilations
-fear, anxiety, diabetic kenoacidosis

Front 14

Trachypnea

Back 14

-shallow and rapid ventilations

Front 15

Cheyne-stokes

Back 15

-wax and wane in regular pattern
-increae rate and depth and then decrease
-to point of apnea (CHF??)

Front 16

Hypoventialtion

Back 16

-low resp rate
-shallow

Front 17

Chronic obstructive breathing

Back 17

-pattern much more irregular
-anything affecting brain
-heat stroke, spinal meningitis

Front 18

Apnea

Back 18

no breathing

Front 19

Barrel Chested

Back 19

ratio more 1:1
-people who are trapping air
-emphysema
-hard to hear lungs and heart
-heart deeper in chet

Front 20

Pectus Excavatum

Back 20

-sternal bone pushed in towards heart and lungs
-depending on depth can affect either the lungs and/or heart
- if indentation not deep-just a different external appearance

Front 21

Pectus Carinatum

Back 21

-sternum pushed out

Front 22

Scoliosis and Kyphosis

Back 22

scoliosis-assymetrical configuration of thorax
kyphosis-hunchback appearance

-in severe cases both can affect the lungs

Front 23

Thorax irregularities on infant

Back 23

-normal to barrel in baby
-round thorax normal

Front 24

Palpate for symmetric expansion

Back 24

-place hands on post. chest wall -thumbs on T9 or T10
-use thumbs to pinch skin together
-patient takes deep breath
-thumbs should move apart symmetrically

Front 25

Palpate for tactile fremitus

Back 25

-use palmar base to get into the 5 ICS
-start over apices and palpate
-patient says "99"
-feel vibration symmetrically
-stronger vibrations-something denser in lungs
-pnemonia
-adelysis-lung shrinks--decreased tactile fremitus

Front 26

Percussion of posterior chest

Back 26

-over lungs, etc
-percuss 9 spots down back
-depth 5-7 cm
-pleural effusion (fluid in pleura)-->tap to see where dullness starts
-know where to drain fluid

Front 27

Sounds of percussion

Back 27

-normal lung=ressonance
-dullness-solid tissue replacing air-filled tissue in lungs
-fluid or organ
-higher and shorter sound
-over bone (rib, scapula)=flat
-should NOT hear any tympany

Front 28

Percuss for Diaphragmatic Excursion

Back 28

-have person exhale
-percuss around T0
-keep percussing downward until dullness arived at viscera of abdomen
-inhale
-percuss
-->should be able to hear resonance and percuss downward to reach dullness again
-excursion should be around 3-5 on both sides

Front 29

Auscultate Lung fields

Back 29

-use diaphragm of stethoscope
-one inspiration and expiration at each spot
-side to side comparison across 9 spots

Front 30

Sounds of Ausculation

Back 30

Vesicular-soft and low pitched
inspiration>expiration
-ICS/lungs
Bronchovesicular-moderate pitch
inspiration =expiration
-in ICS near spine
mainstembronchus
Bronchial-
expiration> inspiration
-over manubrim

Front 31

Pectus Carinatum

Back 31

-sternum pushed out

Front 32

Scoliosis and Kyphosis

Back 32

scoliosis-assymetrical configuration of thorax
kyphosis-hunchback appearance

-in severe cases both can affect the lungs

Front 33

Thorax irregularities on infant

Back 33

-normal to barrel in baby
-round thorax normal

Front 34

Palpate for symmetric expansion

Back 34

-place hands on post. chest wall -thumbs on T9 or T10
-use thumbs to pinch skin together
-patient takes deep breath
-thumbs should move apart symmetrically

Front 35

Palpate for tactile fremitus

Back 35

-use palmar base to get into the 5 ICS
-start over apices and palpate
-patient says "99"
-feel vibration symmetrically
-stronger vibrations-something denser in lungs
-pnemonia
-adelysis-lung shrinks--decreased tactile fremitus

Front 36

Percussion of posterior chest

Back 36

-over lungs, etc
-percuss 9 spots down back
-depth 5-7 cm
-pleural effusion (fluid in pleura)-->tap to see where dullness starts
-know where to drain fluid

Front 37

Sounds of percussion

Back 37

-normal lung=ressonance
-dullness-solid tissue replacing air-filled tissue in lungs
-fluid or organ
-higher and shorter sound
-over bone (rib, scapula)=flat
-should NOT hear any tympany

Front 38

Percuss for Diaphragmatic Excursion

Back 38

-have person exhale
-percuss around T0
-keep percussing downward until dullness arived at viscera of abdomen
-inhale
-percuss
-->should be able to hear resonance and percuss downward to reach dullness again
-excursion should be around 3-5 on both sides

Front 39

Auscultate Lung fields

Back 39

-use diaphragm of stethoscope
-one inspiration and expiration at each spot
-side to side comparison across 9 spots

Front 40

Sounds of Ausculation

Back 40

Vesicular-soft and low pitched
inspiration>expiration
-ICS/lungs
Bronchovesicular-moderate pitch
inspiration =expiration
-in ICS near spine
mainstembronchus
Bronchial-
expiration> inspiration
-over manubrim

Front 41

Auscultation Assessment

Back 41

-when there is bronchovesicular sounds in area that should be vesicular-abnormal
pnemonia--harsher/louder BV sounds

Anything that blocks passage of air will cause diminished or absent breathsounds (decrease length of inspiration)
-mucus, pus, pleural effusion, etc

Front 42

Adventitous Breath Sounds

Back 42

Extra breath sounds on top of normal
-fine crackle crepitations-at end of inspiration
-can't clear by coughing
-caused by air colliding w secretions or alveoli that werent open before popping open
-coarse crackles-beginning of inspiration
sound more like the opening of velcro
-sibilant wheezes-at exhalation (beginning)
-musical
-asthma, heart failure, obstruction
- sonorous (rhonchi)-at exhalation
-moaning or snoring (lower pitched)
Stridor-coup or obstruction
-often in kids
Pleural friction rub-sounds like rubber rubbing together
-pleura swollen and rubbing together

Front 43

Transmitted voice sounds

Back 43

-tests for pnemonia
-auscultation

-bronchophony-99 is clear rather than muffled
-egophony-E to A changes (says E but hears A)
-whispered pectoriloquy-louder, clear whispered 99 rather than faint or absent sound

Front 44

Anterior Chest assessment

Back 44

-like on posterior side, also do:
-symmetric chest expansion (w thumbs)
-tactile fremitus palpation test
-percuss (less to percuss-5 spots)
-auscultate (bronchial on trachea--longer expiration)

Front 45

Atelactasis

Back 45

-lobar obstruction
-mucus caught in bronchus-->part of lung past it deflates
findings:
-trachea-shifted toward affcted side
-tactile fremitus-none
-percussion-dull over airless area
-breath sounds-absent
-adventitious sounds-none

Front 46

Consolidation

Back 46

-pneumonia
-bacteria, virus, protozoa
-blood vessels around alveoli
findings:
-trachea-midline
-tactile fremitus-increased over affected area
-bronchophony, egophony, whispered pectoriloquy
-percussion-dull over affected airless area
-breath sounds-bronchial (louder) over involved area
-adventitious sounds-late inspiratory crackles over affected area
-

Front 47

Bronchitis

Back 47

-inflammation of bronchi by irritants or infection
chronic-cough and hyper secretion of mucus for at least 3 months every year for 2 or more years
-caused by smoking
findings:
-trachea-midline
-tactile fremitus-normal
-percussion-resonant (normal)
-breath sounds-vesicular except over large bronchi or trachea
-short of breath
adventitious sounds-none of scattered coarse crackles in early inspiration and expiration, wheezes and rhonchi

-productive cough, cyanosis, use of accessory muscles for deeper breath, atelactasis, mucus beyond obstruction

Front 48

Emphysema

Back 48

-over-distended alveoli
-form of chronic obstructive pulmonary disease (like chronic bronchitis)
-permanent expansion of distal air spaces
-alveoli loose elasticity-->can't get air out
Findings:
-trachea-midline
-tactile fremitus-decreased
percussion-hyperressonant
-breath sounds-decreased to absent
-shortness of breath w exertion, long expiration w strain
-adventitious sounds-absent of scattered coarse crackles in early inspiration and expiration, rhonchi and wheezing w chronic bronchitis

-->barrel chested

Front 49

Asthma

Back 49

-chronic reactive airway disease
-muscles around bronchioles cause them to go into spasms
-->increased mucus secretions
-->mucous becomes edema
-mostly in children
findings:
-trachea-midline
-tactile fremitus-drecreased
-percussion-ressonant to hyperressonant
-breath sounds-often obscured by wheezes
-adventitious sounds-wheezes, sometimes crackles

Front 50

Pleural Effusion

Back 50

-a little more pleural fluid in cavity
-->block transmission of sound
-if a lot of fluid-need removal
findings:
-trachea-shifted toward opposite side in large effusion
-tactile fremitus-decreased to absent
-percussion-full to flat over fluid
-breath sounds-decreased to absent-but bronchial sounds may be heard near top of large effusion
-adventitious sounds-none, except possible rub

Front 51

Pneumothorax

Back 51

-traumatic or spontaneous
-pennetrating injury (stab wound)
-->open--in chest wall
closed-motor vehicle accident, fall
spontaneous-opening in lung
-mostly in older people w COPD (emphysema)
-bleb bursts-->punctures the lung
findings:
-trachea-shifted towards opposite side if much air
-tactile fremitus-decreased to absent over pleural air
-percussion-hyperressonant to tympanic over pleural air
-breath sounds-decreased to absent over pleural air
-adventitious sounds-none, except possible pleural rub

Front 52

Congestive Heart Failure

Back 52

-pushes on alveoli
findings:
-trachea-midline
-tactile fremitus-decreased
-percussion-resonant
-breath sounds-vesicular
-adventitious sounds-late inspiratory crackles in dependent portions of lungs
-possibly wheezes