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154 Cards in this Set

  • Front
  • Back
dyspnea
Shortness of breath
hemoptysis
Blood-streaked sputum
A clenched fist over the sternum suggests...
angina pectoris
a finger pointing to a tender area on the chest wall suggests....
musculoskeletal pain
a hand moving from neck to epigastrum suggests....
heartburn
The Seven Attributes of a Symptom:
1. Location. Where is it? Does it radiate?
2. Quality. What is it like?
3. Quantity or severity. How bad is it? (For pain, ask for a rating on a scale of 1 to 10.)
4. Timing. When did (does) it start? How long does it last? How often does it come?
5. Setting in which it occurs. Include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness.
6. Remitting or exacerbating factors. Is there anything that makes it better or worse?
7. Associated manifestations. Have you noticed anything else that accompanies it?
Aside from lung conditions, chest pain may arise from...
cardiac, vascular, gastrointestinal, musculoskeletal, skin, and also commonly anxiety
Chest pain is usually from...
inflammation of the adjacent parietal pleura; lung tissue has no pain fibers
People who have had a heart attack usually describe....
an associated pain as a “crushing” sub-sternal pain (deep to the sternum) that does not disappear with rest.
The weakest part of a rib is...
is just anterior to its angle
Multiple rib fractures may cause...
a sizable segment of thoracic wall to move freely. The loose segment of the wall moves paradoxically (inward on inspiration and outward on expiration), called flail chest is a painful injury and impairs ventilation
Pleuritis (Pleurisy)
During inspiration and expiration, the sliding of normally smooth, moist pleurae makes no detectable sound during auscultation of the lungs (listening to breath sounds)
Inflammation of the pleura, pleuritis (pleurisy), makes the lung surfaces rough
The resulting friction (pleural rub) is detectable with a stethoscope. It sounds like a clump of hair being rolled between the fingers. Acute pleuritis is marked by sharp, stabbing pain, especially on exertion, when respiration may be increased even slightly
Herpes Zoster Infection
causes a classic, dermatomally distributed skin lesion—shingles—a painful condition .
primarily a viral disease of spinal ganglia, usually a reactivation of the varicella-zoster virus (VZV), or chickenpox virus.
After invading a ganglion, the virus produces a sharp burning pain in the dermatome supplied by the involved nerve
The affected skin area becomes red, and vesicular eruptions appear
Pain in lung conditions such as pneumonia or pulmonary infarction usually arises from...
inflammation of the adjacent parietal pleura
the pain of pericarditis stems from...
inflammation of the adjacent parietal pleura; the pericardium also has few pain fibers
Prolonged recurrent coughing can cause....
Muscle strain
Referred Pain
The convergence of somatic and visceral afferent fibers to a common level of the spinal cord confuses the relationship between the perceived and actual sites of pain, a phenomenon known as referred pain.
Pain impulses from a particular organ are consistently projected to the same well-defined skin area
Dyspnea commonly results from...
cardiac or pulmonary disease
Anxious patients may have..
episodic dyspnea during both rest and exercise, and hyperventilation.
At other times, they may sigh frequently.
They may describe difficulty taking a deep enough breath, or a smothering sensation with inability to get enough air, along with paresthesias, or sensations of tingling or “pins and needles” around the lips or in the extremities
Wheezes
musical respiratory sounds; may be audible to others
Wheezing suggests...
partial airway obstruction (ex.secretions, tissue inflammation, or a foreign body)
Cough
typically is a reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi
Cough stimuli include...
mucus, pus, and blood, as well as external agents such as dust, foreign bodies, or even extremely hot or cold air
Other causes include inflammation of the respiratory mucosa and pressure or tension in the air passages from a tumor or enlarged peribronchial lymph nodes
acute cough
less than 3 weeks
subacute cough
3 to 8 weeks
Chronic cough
more than 8 weeks
Mucoid sputum is...
translucent, white, or gray
Purulent sputum is....
yellowish or greenish.
Foul-smelling sputum in...
anaerobic lung abscess
Tenacious sputum in...
cystic fibrosis
Large volumes of purulent sputum in...
bronchiectasis or lung abscess
COPD
chronic obstructive pulmonary disease including asthma, bronchiolitis, chronic bronchitis, and cystic fibrosis.
The conducting airways are involved in these major pulmonary diseases
Obstruction of airflow through the airways is commonly caused by...
increased mucus, airway inflammation, and smooth muscle constriction.
Asthma
involves both large and small airways and is characterized by inflammation of the airways and reversible airway smooth muscle constriction (bronchospasm).
Bronchiolitis
a disease of the small airways. It usually occurs in young infants and is caused by viruses, most commonly respiratory syncytial virus.
Chronic bronchitis
a disease of smokers, is associated with a marked increase in mucus-secreting cells in the airways and an increase in mucus production.
Cystic fibrosis
a genetically inherited disease that adversely affects chloride channels in exocrine glands.
In the lung this results in obstruction via abnormal mucus accumulation and leads to recurrent pulmonary infections.
Crackles (rales)
a popping sound usually heard during inspiration on auscultation in individuals with premature airway closure.
crackles are due to the opening of airways during inspiration that closed (i.e., were compressed) during the previous exhalation.
also heard in individuals with emphysema, in which there is a decrease in lung elastic recoil.
Crackles can be due to...
mucus accumulation, airway inflammation, fluid in the airways, or any mechanism responsible for airway narrowing or compression.
premature airway closure
caused from collaspse of small airways that are devoid of cartilage
results in a less than maximal exhalation that is known as air trapping and produces an increase in lung volume
In emphysema...
the elastic tissue in the alveolar and capillary walls is progressively destroyed, which results in increased lung compliance and decreased elastic recoil. The decrease in elastic recoil results in movement of the equal pressure point toward the alveolus and premature airway closure.
Increases in lung volumes from COPD...
increase the work of breathing by stretching the respiratory muscles and decreasing their efficiency.
What happens in chronic bronchitis?
accumulation of mucus and airway inflammation cause the equal pressure point to move toward the alveolus, which leads to premature airway closure and increases in RV, FRC, and TLC. Airway resistance and the work of breathing are increased, but lung compliance is normal.
Hemoptysis
the coughing up of blood from the lungs; it may vary from blood-streaked phlegm to frank blood

Blood originating in the stomach is usually darker than blood from the respiratory tract and may be mixed with food particles.
Blood may also originate from the mouth, pharynx, or gastrointestinal tract
When vomited, blood probably originates in the...
gastrointestinal tract
Occasionally, however, blood from the nasopharynx or the gastrointestinal tract is aspirated and then coughed out.
When a lung collapses..
it occupies less volume within the pulmonary cavity and the pulmonary cavity does not increase in size (in fact, it may decrease in size) during inspiration.
Reduction in size will be evident radiographically on the affected side by elevation of the diaphragm above its usual levels, intercostal space narrowing (ribs closer together), and displacement of the mediastinum and trachea (mediastinal shift; most evident via the air-filled trachea within it on x-ray) toward the affected side.
Smoking death stats
Smoking accounts for 1 in 5 U.S deaths each year
Five A's of smoking cessation
Ask about smoking at each visit
Advise patients regularly to stop smoking using a clear, personalized message
Assess patient readiness to quit
Assist patients to set stop dates and provide educational materials for self-help
Arrange for follow-up visits to monitor and support patient progress
On chest/rib palpation...
costal cartilages and ribs feel identical.
Floating Ribs
The 11th and 12th ribs, the “floating ribs,” have no anterior attachments. The cartilaginous tip of the 11th rib usually can be felt laterally, and the 12th rib may be felt posteriorly.
Triangle of Auscultation
a small triangular gap in the musculature near the inferior angle of the scapula.
formed from the superior horizontal border of the latissimus dorsi, the medial border of the scapula, and the inferolateral border of the trapezius.
This gap is a good place to examine posterior segments of the lungs with a stethoscope. When the scapulae are drawn anteriorly by folding the arms across the chest and the trunk is flexed, the auscultatory triangle enlarges and parts of the 6th and 7th ribs and 6th intercostal space are subcutaneous.
Breath sounds over the trachea and bronchi..
have a different quality than breath sounds over the lung parenchyma. The trachea bifurcates into its mainstem bronchi at the levels of the sternal angle anteriorly and the T4 spinous process posteriorly.
The conducting portion of the bronchial tree...
extends from the tracheal bifurcation to the terminal bronchiole, inclusive.
The respiratory portion of the bronchial tree...
consists of the respiratory bronchiole, alveolar ducts, alveolar sacs, and alveoli
The lungs can be expanded and contracted how?
two ways:
(1) by downward and upward movement of the diaphragm to lengthen or shorten the chest cavity
(2) by elevation and depression of the ribs to increase and decrease the anteroposterior diameter of the chest cavity
Normal quiet breathing
is accomplished almost entirely by movement of the diaphragm.
During inspiration, contraction of the diaphragm pulls the lower surfaces of the lungs downward. Then, during expiration, the diaphragm simply relaxes, and the elastic recoil of the lungs, chest wall, and abdominal structures compresses the lungs and expels the air.
Heavy breathing
the elastic forces are not powerful enough to cause the necessary rapid expiration, so extra force is achieved mainly by contraction of the abdominal muscles, which pushes the abdominal contents upward against the bottom of the diaphragm, thereby compressing the lungs
The second method for expanding the lungs is...
to raise the rib cage. This expands the lungs because, in the natural resting position, the ribs slant downward.
The most important muscles that raise the rib cage are...
the external intercostals, but others that help are the (1) sternocleidomastoid muscles, which lift upward on the sternum; (2) anterior serrati, which lift many of the ribs; and (3) scaleni, which lift the first two ribs.
The muscles that pull the rib cage downward during expiration are mainly...
(1) the abdominal recti, which have the powerful effect of pulling downward on the lower ribs at the same time that they and other abdominal muscles also compress the abdominal contents upward against the diaphragm
(2) internal intercostals.
Breathing
largely an automatic act, controlled in the brainstem and mediated by the muscles of respiration
When a healthy person lies supine, breathing movements....
of the thorax are relatively slight.

the abdominal movements are usually easy to see.
In the sitting position, breathing movements...
of the thorax become more prominent
Breathing during exercise and in certain diseases...
extra work is required to breathe, and accessory muscles join the inspiratory effort.
The sternocleidomastoids are the most important of these, and the scalenes may become visible. Abdominal muscles assist in expiration
A healthy resting adult breathes how?
quietly and regularly about 12 to 20 times a minute
<12 breaths per minute suggests...
central respiratory depression
>20 breaths per minute suggests...
hypoxia, pain, or anxiety
Cyanosis and clubbing of the nails signals...
hypoxia.
Seen in lung abscesses, malignancy, and congenital heart disease
Clubbing
Clinically a bulbous swelling of the soft tissue at the nail base, with loss of the normal angle between the nail and the proximal nail fold.
The angle increases to 180° or more, and the nail bed feels spongy or floating.
mechanism unknown but involves vasodilatation with increased blood flow to the distal portion of the digits and changes in connective tissue, possibly from hypoxia, changes in innervation, genetics, or a platelet-derived growth factor from fragments of platelet clumps.

Seen in congenital heart disease, interstitial lung disease and lung cancer, inflammatory bowel diseases, and malignancies
Stridor
a high-pitched wheeze, is an ominous sign of airway obstruction in the larynx or trachea
Inspiratory contraction of the sternocleidomastoids and scalenes at rest signals....
severe difficulty in breathing.
Lateral displacement of the trachea occurs in.....
pneumothorax, pleural effusion, or atelectasis
Unilateral or bilateral impairment or lagging of respiratory movement suggests...
disease of the underlying lung or pleura
Abnormal retraction of the interspaces during inspiration
severe asthma, COPD, or upper airway obstruction
Intercostal tenderness occurs over...
inflamed pleura
Chest bruises occur over...
a fractured rib
sinus tracts in the chest usually indicate...
infection of the underlying pleura and lung (as in tuberculosis, actinomycosis
sinus tracts
blind, inflammatory, tubelike structures opening onto the skin
Causes of unilateral decrease or delay in chest expansion include:
chronic fibrosis of the underlying lung or pleura, pleural effusion, lobar pneumonia, pleural pain with associated splinting, and unilateral bronchial obstruction
Fremitus
refers to the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient is speaking.
Fremitus is decreased or absent when...
the voice is soft or when the transmission of vibrations from the larynx to the surface of the chest is impeded.
Causes include a very thick chest wall; an obstructed bronchus; COPD; separation of the pleural surfaces by fluid (pleural effusion), fibrosis (pleural thickening), air (pneumothorax), or an infiltrating tumor.
To detect fremitus...
use either the ball (the bony part of the palm at the base of the fingers) or the ulnar surface of your hand to optimize the vibratory sensitivity of the bones in your hand. Ask the patient to repeat the words “ninety-nine” or “one-one-one.” If fremitus is faint, ask the patient to speak more loudly or in a deeper voice.
asymmetric decreased fremitus occurs in...
unilateral pleural effusion, pneumothorax, neoplasm from decreased transmission of low frequency sounds
asymmetric increased fremitus occurs in...
unilateral pneumonia from increased transmission
Fremitus is typically more prominent in...
the interscapular area than in the lower lung fields and is often more prominent on the right side than on the left.

It disappears below the diaphragm.
Percussion helps establish
whether the underlying tissues (5-7 cm deep) are air-filled, fluid-filled, or solid
Percussion
sets the chest wall and underlying tissues in motion, producing audible sound and palpable vibrations. Percussion helps you establish whether the underlying tissues are air-filled, fluid-filled, or solid.
It penetrates only 5 cm to 7 cm into the chest, however, and will not help you to detect deep-seated lesions.
During percussion, strike using....
the tip of the plexor finger, not the finger pad. Your finger should be almost at right angles to the pleximeter.
If a louder percussion note is needed...
apply more pressure with the pleximeter finger (this is more effective for increasing percussion note volume than tapping harder with the plexor finger).
During percussion, omit...
the areas over the scapulae—the thickness of muscle and bone alters the percussion notes over the lungs
Flat percussion note location and pathology:
thigh; large pleural effusion
Dull percussion note location and pathology:
Liver; lobar pneumonia
Resonant percussion note location and pathology:
Healthy lung; simple chronic bronchitis
Hyperresonant percussion note location and pathology:
usually no location; COPD, pneumothorax
Tympanic percussion note location and pathology:
Gastric air bubble or puffed-out cheek; large pneumothorax
Cranial to caudal, percussion sounds go from...
resonant to dull at the level of the diaphragm
An abnormally high percussion level suggests...
pleural effusion, or a high diaphragm as in atelectasis or diaphragmatic paralysis
Percussion dullness replaces resonance when....
fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers. Examples include: lobar pneumonia, in which the alveoli are filled with fluid and blood cells; and pleural accumulations of serous fluid (pleural effusion), blood (hemothorax), pus (empyema), fibrous tissue, or tumor.
Generalized hyperresonance may be heard....
over the hyperinflated lungs of COPD or asthma, but is not a reliable sign
Unilateral hyperresonance suggests...
a large pneumothorax or possibly a large air-filled bulla in the lung.
Auscultation of the lungs
the most important examination technique for assessing air flow through the tracheobronchial tree

Together with percussion, it also helps to assess the condition of the surrounding lungs and pleural space
Decreased breath sounds are associated with...
COPD, pleural effusion, pneumothorax, and emphysema.
Bronchial breath sounds are associated with....
consolidation, in which bronchial sounds have increased transmission to areas where vesicular sounds should be heard. Added adventitious sounds that are abnormal include rhonchi or wheezes, crackles, or rubs
Tests for consolidation are:
egophony, tactile fremitus, and bronchophony (whispered pectoriloquy is a form of bronchophony), and replacement of normal vesicular breath sounds with bronchial or bronchovesicular sounds in an involved area.
Auscultation involves:
(1) listening to the sounds generated by breathing
(2) listening for any adventitious (added) sounds
(3) if abnormalities are suspected, listening to the sounds of the patient’s spoken or whispered voice as they are transmitted through the chest wall
If the patient is cold or tense, breath sounds may manifest...
muscle contraction sounds—muffled, low-pitched rumbling or roaring noises. A change in the patient’s position may eliminate this noise.
Normal breath sounds are:
Vesicular, are soft and low pitched and are from the flow of air in the smallest bronchioles and into alveoli. They are heard through inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration.
Bronchovesicular, with inspiratory and expiratory sounds about equal in length, at times separated by a silent interval.
Detecting differences in pitch and intensity is often easier during
expiration.
Bronchial breath sounds
are from the bronchi, louder and higher in pitch, with a short silence between inspiratory and expiratory sounds
Tracheal sounds
very loud and relatively high pitched, from the trachea
Breath sounds may be decreased when...
air flow is decreased (as in obstructive lung disease or muscular weakness) or when the transmission of sound is poor (as in pleural effusion, pneumothorax, or COPD)
Breath sounds are usually louder...
in the lower posterior lung fields and may also vary from area to area
Adventitious breath sounds often lead to....
diagnosis of cardiac and pulmonary conditions
Fine late inspiratory crackles that persist from breath to breath suggest...
abnormal lung tissue
Clearing of crackles, wheezes, or rhonchi after coughing or position change suggests....
inspissated secretions, as in bronchitis or atelectasis.
In some normal people, crackles may be heard....
at the lung bases anteriorly after maximal expiration. Crackles in dependent portions of the lungs may also occur after prolonged recumbency.
Findings predictive of COPD include....
combinations of symptoms and signs, especially wheezing by self-report or examination, plus history of smoking, age, and decreased breath sounds.
Diagnosis requires pulmonary function tests such as spirometry
If you hear abnormally located bronchovesicular or bronchial breath sounds...
assess transmitted voice sounds.
Increased transmission of voice sounds suggests...
that air-filled lung has become airless.
bronchophony
Louder, clearer voice sounds (“ninety-nine”)
When “ee” is heard as “ay,”....
an E-to-A change (egophony) is present, as in lobar consolidation from pneumonia. The quality sounds nasal
With percussion of the anterior chest....
the heart normally produces an area of dullness to the left of the sternum from the 3rd to 5th rib interspaces
Supraclavicular retraction of the lower interspaces during inspiration
Severe asthma, COPD, or upper airway obstruction
Local lag or impairment in respiratory movement often present in....
Underlying disease of lung or pleura
Palpation of the anterior chest has four potential uses
Identify tender areas
Fremitus is usually decreased or absent...
over the precordium.
If you hear abnormally located bronchovesicular or bronchial breath sounds...
assess transmitted voice sounds.
Increased transmission of voice sounds suggests...
that air-filled lung has become airless.
bronchophony
Louder, clearer voice sounds (“ninety-nine”)
When “ee” is heard as “ay,”....
an E-to-A change (egophony) is present, as in lobar consolidation from pneumonia. The quality sounds nasal
Dullness replaces resonance when...
fluid or solid tissue replaces air-containing lung or occupies the pleural space.
Because pleural fluid usually sinks to the lowest part of the pleural space (posteriorly in a supine patient), only a very large effusion can be detected anteriorly
louder, clearer whispered sounds
whispered pectoriloquy
The hyperresonance of COPD may totally replace..
cardiac dullness
The dullness of right middle lobe pneumonia typically occurs...
behind the right breast. Unless you displace the breast, you may miss the abnormal percussion note
As you percuss down the chest on the left...
the resonance of normal lung usually changes to the tympany of the gastric air bubble.
Percussion of a lung affected by COPD often....
displaces the upper border of the liver downward. It also lowers the level of diaphragmatic dullness posteriorly
Anterior breath sounds are usually louder in the...
upper anterior lung fields
Anterior bronchovesicular breath sounds may be heard...
over the large airways, especially on the right
Local pain and tenderness of one or more ribs suggest...
fracture.
By anteroposterior compression of the chest, you can help to distinguish a fracture from soft-tissue injury. With one hand on the sternum and the other on the thoracic spine, squeeze the chest
An increase in the local pain from anteroposterior compression of the chest (distant from your hands) suggests...
rib fracture rather than just soft-tissue injury
Crackles have two leading explanations:
(1) result from a series of tiny explosions when small airways, deflated during expiration, pop open during inspiration. This mechanism probably explains the late inspiratory crackles of interstitial lung disease and early congestive heart failure. (2)result from air bubbles flowing through secretions or lightly closed airways during respiration. This mechanism probably explains at least some coarse crackles
Late inspiratory crackles
may begin in the first half of inspiration but must continue into late inspiration.
usually fine, fairly profuse, and persist from breath to breath.
appear first at the bases of the lungs, spread upward as the condition worsens, and shift to dependent regions with changes in posture.
Causes include interstitial lung disease (such as fibrosis) and early congestive heart failure
Early inspiratory crackles
appear and end soon after the start of inspiration.
are often coarse and relatively few in number.
Expiratory crackles are sometimes associated.
Causes include chronic bronchitis and asthma
Midinspiratory and expiratory crackles are heard in....
bronchiectasis but are not specific for this diagnosis. Wheezes and rhonchi may be associated
Wheezes
occur when air flows rapidly through bronchi that are narrowed nearly to the point of closure.
They are often audible at the mouth as well as through the chest wall.
Causes of wheezes throughout the chest include...
asthma, chronic bronchitis, COPD, and congestive heart failure (cardiac asthma)
In asthma, wheezes....
may be heard only in expiration or in both phases of the respiratory cycle
Rhonchi suggest...
secretions in the larger airways.
In chronic bronchitis, wheezes and rhonchi...
often clear with coughing
Silent chest
is ominous and warrants immediate attention.
Persistent localized wheezing suggests...
partial obstruction of a bronchus, as by a tumor or foreign body.
It may be inspiratory, expiratory, or both.
Stridor
A wheeze that is entirely or predominantly inspiratory
Pleural Rub
(or pleural friction rub)
Pleural rub sounds....
resemble crackles acoustically, although they are produced by different pathologic processes.
The sounds may be discrete, but sometimes are so numerous that they merge into a seemingly continuous sound.
A rub is usually confined to a relatively small area of the chest wall, and typically is heard in both phases of respiration. When inflamed pleural surfaces are separated by fluid, the rub often disappears