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127 Cards in this Set
- Front
- Back
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Pectus Excavatum
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a depression in lower sternum
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Pectus Carinatum
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An anteriorly displaced sternum
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Traumatic flail chest
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- Paradoxical mvmts of the thorax that results from multiple rib fractures
- Area injured caves inward during inspiration and outward during expiration |
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*How to find 2nd rib from suprasternal notch
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5cm inferior to sternal angle and laterally
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Sternal angle - AKA...
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Angle of Loius
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*Location for tension pneumothorax needle insertion
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*2nd intercostal space
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*Location for chest tube insertion
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*4th intercostal space (landmark for male nipple)
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last rib to articulate with the sternum
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7th rib
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8th-10th ribs articulate w/ ...
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costal cartilages
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Floating ribs
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11th and 12th, no anterior conenction
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*Inferior tip of scapula lies at the level of what rib?
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*7th rib/7th interspace
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*Location for thoracentesis
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*T7-T8 interspace
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Apex of the lungs rise _____ above ______
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2-4cm above clavicles
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Lower border of lung crosses the ____ rib at the midclavicular line
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6th rib
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Lower border of lung crosses the ____ rib at the midaxillary line
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8th rib
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Lung bases extend to _____ posteriorly
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T10 spinous process
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*This spinous process approximates the location of the oblique fissures of the lungs
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*T3
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*The horizontal fissure of the R lung runs close to the ____ rib (anteriorly) and meets the oblique fissure in the midaxillary line near the ____ rib
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*4th rib, 5th rib
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Location of trachea bifurcation
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@ sternal angle anteriorly, T4 posteriorly
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Common complaints regarding chest & lungs
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- Chest pain
- SOB - Wheezing - Cough - Hemoptysis |
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Possible causes of chest pain
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- CV
- Pulmonary - GI - MSK - Skin - Anxiety |
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Cardiovascular as cause of chest pain.
- Location |
Substernal, shoulder, jaw, neck
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Cardiovascular as cause of chest pain.
- Quality |
- Pressure
- Aching - Heavy - "Crushing" - "Ripping"/"tearing" - Sharp |
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Cardiovascular as cause of chest pain.
- Timing |
1-20 min
- Intermittent (angina) - Constant (pericarditis and dissection) |
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Cardiovascular as cause of chest pain.
- Aggravating factors |
- Exertion (angina/MI)
- Breathing and position (pericarditis) |
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Cardiovascular as cause of chest pain.
- Alleviating factors |
- Rest
- Sitting forward (pericarditis) |
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Cardiovascular as cause of chest pain.
- Associated sx |
- Dyspnea
- Nausea - Diaphoresis (angina/MI) |
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*Clenched fist over anterior chest, typical in coronary syndrome
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*Levine sign
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Tracheobronchitis: location, s/s, quality, severity, and a/a factors.
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Location - upper chest (upper sternum or on either side of the sternum)
Quality: burning Severity: mild-moderate Aggravated by: coughing and deep breathing Alleviated by: lying on involved side |
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Pleuritic pain: location, quality, timing, severity, and aggravating factors
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Location: anywhere on the chest wall
Quality: sharp/stabbing Severity: mod - severe Timing: constant Aggravated by: inspiration, coughing/breathing/chest wall motion |
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Bronchospasm: location, quality, severity, aggravating factors, and assoc. sx
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Location: substernal
Quality: sharp - ache Severity: mild-severe TIming: episodic Aggravated by: cough/deep breathing Assoc. sx: wheezing/dyspnea |
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GERD: location, quality, severity, and a/a factors
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Location: Substernal, to back
Quality: burning/squeezing Severity: mild-severe Aggravated by: worse after meals and when lying down Alleviated by: antacids (sometimes) * Hand moving from neck to epigastrum |
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Esophageal spasm: location, quality, severity, and a/a factors.
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Location: Substernal to jaw or back
Quality: Squeezing Severity: mild-severe Aggravated by: swallowing Alleviated by: occasionally by belching and antacids |
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Peptic ulcer: location, quality, severity, and alleviating factors
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Location: substernal to back/abd
Quality: aching -burning Severity: mild-severe Alleviated by: initially may improve w/ food, then will worsen later |
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Gallbladder: location, quality, severity, a/a factors
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Location: substernal to back/abd
Quality: aching-burning Severity: mild-severe Aggravated by: greasy food Alleviated by: initially may improve w/ food, then will worsen later |
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MSK chest pain: location, quality, severity, timing, aggravating factors, assoc. sx
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Location: any location on chest wall
Quality: stabbing - ache Severity:mild-severe Timing: hours-days, constant to variable Aggravating factors: chest motion Assoc. sx - tender over area * Able to point to painful area on chest wall |
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Anxiety as cause of chest pain: location, quality, severity, timing, aggravating factors, assoc. sx
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"Just can't get deep enough breath"
Location: any Quality: ache-dull-sharp-pressure Severity: mild-severe Timing: variable, usually hours-days Aggravating factors: may follow effort or emotional event (not always) Assoc. sx: breathlessness, palpitations, weakness, anxiety, tingling oral and hands/feet |
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Angina pectoris: location, quality, severity, timing, a/a factors, assoc. sx
(All very similar to MI) |
Location: retrosternal or across anterior chest, sometimes radiating to shoulders, arms, neck, lower jaw, or upper abd
Quality: pressing, squeezing, tight, heavy, occasional burning Severity: mild-mod, sometimes just discomfort Timing: 1-3 min, but to 10. Prolonged episodes up to 20 min. Aggravating factors: exertion, esp in cold. Meals, emo stress, can occur @ rest Alleviating factors: rest, nitroglycerin Assoc. sx: sometimes dyspnea, nausea, sweating |
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Angina pectoris
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Temporary myocardial ischemia, usually secondary to coronary atherosclerosis
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Pericarditis: location, quality, severity, timing, a/a factors, assoc. sx
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Location: Precordial, may radiate to tip of shoulder and to the neck
Quality: sharp, knifelike Severity: often severe Timing: Persistent Aggravated by: breathing, changing position, coughing, lying down, sometimes swallowing Alleviated by: sometimes sitting forward |
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Dissecting aortic aneurysm: location, quality, severity, timing, a/a factors, assoc. sx
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Location: anterior chest, radiating to neck, back, or abd
Quality: ripping, tearing Severity: very severe Timing: abrupt onset, early peak, persistent for hrs or more Aggravated by: HTN Assoc. sx: syncope, hemiplegia, paraplegia |
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Costochondritis: location, quality, severity, timing, a/a factors, assoc. sx
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Location: Often below L breast of along costal cartilages
Quality: stabbing, sticking, dull, aching Severity: variable Timing: fleeting - hours to days Aggravated by: mvmt of chest, trunk, arms Assoc. sx: often local tenderness |
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Regarding chest pain:
Are there pain fibers in the lung? What is causing the pain in certain lung conditions (ie: PNA or pulmonary infarction)? Where else can pain be originating from? |
Lung contains no pain fibers
Pain arising from inflammation of adjacent parietal pleura Muscle stain Pericardium contains few pain fibers |
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If pt presents w/ dyspnea, while assessing HPI be sure to
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Determine severity based on pt's daily activities
Ie: How many flights of stairs? Walking across room? |
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MC causes of chest pain in children
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Anxiety, costochondritis
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SOB assoc. w/ CHF
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Orthopnea, DOE, peripheral edema, cough, usually gradual onset but could be sudden in flash edema
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Chronic bronchitis: def, timing, a/a factors, assoc. sx, setting
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Excessive mucus production in bronchi, followed by chronic obstruction of airways
Timing: chronic productive cough, progressive dyspnea Aggravating factors: exertion, inhaled irritants, resp. inf. Alleviating factors: expectoration, rest, though dyspnea may become persistent Assoc. sx: dyspnea, chronic productive cough, recurrent resp. inf., wheezing may develop Setting: Hx of smoking, air pollutants, recurrent resp. inf. |
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COPD: def, timing, a/a assoc. sx, setting
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Group of chronic obstructed diseases characterized by over-distention of air spaces distal to terminal bronchioles, w/ destruction of alveolar septa and chronic obstruction of the airways (Includes emphysema and chronic bronchitis)
Timing: *slowly progressive dyspnea and cough Aggravating factors: exertion Alleviating factors: rest, though dyspnea may become persistent Assoc. sx: dyspnea, cough w/ scant mucoid sputum Setting: Hx of smoking, air pollutants, familial deficiency in a1-antitrypsin |
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Asthma: def, timing, a/a factors, assoc. sx
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Chronic obstructive disease of airways characterized by variable and reversible inflammation, mucous plugging, and bronchial smooth m constriction
Timing: acute episodes b/w sx-free periods. Nocturnal episodes common. Aggravating factors: allergens, irritants, respiratory infections, exercise, and emotion Alleviating factors: separation from aggravating factors Assoc. sx: dyspnea, wheezing, cough, tightness in chest, prolonged exp |
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Left Sided Heart Failure (AKA L Ventricular failure or mitral stenosis): def, timing, a/a factors, assoc. sx
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Failure of heart pump function resulting in increased pressure in the pulmonary vv causing congestion and interstitial edema
Timing: may progress slowly or suddenly, as in acute pulmonary edema Aggravating factors: exertion, lying down Alleviating factors: rest, sitting up, though dyspnea may be persistent Assoc. sx: dyspnea, often cough, **orthopnea, **PND, sometimes wheezing |
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Diffuse Interstitial Lung Diseases (ie: sacoidosis, widespread neoplasms, asbestosis, and idiopathic pulmonary fibrosis): timing, a/a factors, assoc. sx
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Abn and widespread infiltration of cells, fluid, and collagen into interstitial spaces b/w alveoli.
Timing: progressive dyspnea Aggravating factors: exertion Alleviating factors: rest, but dyspnea may be persistent Assoc. sx: dyspnea, often weakness, fatigue, cough less common than in other diseases |
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Pneumothorax: def.,timing, assoc. sx, setting
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Leakage of air into pleural space, usually unilateral
Tension: when it leads to significant resp. and circulatory impairment - EMERGENCY! Spontaneous: Primary or secondary Timing: sudden onset of dyspnea Assoc. sx: pleuritic pain, cough, dyspnea, RD Setting: trauma, chronic lung disease, surgery, thin male |
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Pneumonia: def, timing, assoc. sx
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Inflammation of lung parenchyma from the respiratory bronchioles to the alveoli
Timing: an acute illness, varies w/ causative agent Assoc. sx: pleuritic pain, cough, sputum, fever (not always present) |
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PE: def, timing, assoc. sx, aggravating factors, setting
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Sudden occlusion of all or parts of pulmonary arterial tree, MC by a DVT
Timing: SUDDEN ONSET of dyspnea Assoc. sx: often none. retrosternal pain if lg. occlusion. Pleuritic pain, cough, hemoptysis may follow if pulmonary infarction ensues. Sx of anxiety, palpitations, tingling of hands/feet, lightheadedness. Aggravating factors: exertion to non specific Setting: postpartum or post-op, prolonged bedrest, CHF, chronic lung disease, fx of hip or leg, DVT |
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Wheezing
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- Musical respiratory sound heard w/ inspiration and expiration
- "Accordion sound" - Typically signifies airway obstruction from secretions, inflammation, or foreign body |
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Cough: descriptions and causes
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- Typically a reflex response to stimuli that irritate R in larynx, trachea, or large bronchi
- Can be dry or productive - Causes: irritants (ie: mucus, pus, blood, dust, foreign bodies, heat/cold, medication, other), inflammation of respiratory mucosa, pressure/tension in airways from tumor, or enlarged peribronchial lymph nodes * can be CV in origin, ie: w/ L-sided heart failure |
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MC cause of acute cough
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viral URI
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Hemoptysis: origin, color, always concerning sign for ____
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- Blood could be postnasal, mouth, pharynx, or GI source
- Bright red - rust colored (blood from stomach usually darker and may have food particles) - Always concerning for neoplasms - When vomited, it probably originates from GI tract - Always quantify amt, freq, and last episode |
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Hemoptysis most often seen in ______
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Pts w/ CF
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Orthopnea def and common in these pts
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- Dyspnea that occurs when pt is lying down and improves when sitting up
- common in CHF pts |
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PND def
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Sudden dyspnea and orthopnea that awakens pt from sleep
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Kussmal breathing
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deep, labored breathing pattern
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Cheyne- Stokes respirations
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deep breathing alternating w/ periods of apnea
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*Tracheal deviation in pneumothorax
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*deviates away from affected side
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Retractions of the chest
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- Intercostal, during inspiration
- Seen in severe asthma, COPD, or upper airway obstruction - Most apparent in lower interspaces |
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Abn chest expansion seen in _____
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Fibrosis, pleural effusion, lobal PNA, bronchial obstruction
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Fremitus: def, how to test, decreased in ____, increased in_____
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*Palpable vibrations transmitted through the bronchopulmonary tree to the chest wall
Compare L to R using ball or ulnar aspect of hand Decreased: thick chest wall, obstructed bronchus, COPD, pleural effusion, fibrosis, air, or tumor Increased: unilateral PNA |
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Sinus tracts: def, usually indicates, seen in ____
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- Blind, inflammatory, tubelike structures opening onto the skin
- Usually indicates inf of underlying pleura and lung - Seen in TB, actinomycosis |
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Percussion of chest wall: directions and what will it tell you regarding underlying tissues?
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- Use lightest percussion that produces a clear note
- Helps establish whether underlying tissues (5-7cm deep) are air-filled, fluid-filled, or solid |
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Percussion notes: intensity, pitch, duration, ex
Flatness.... |
Soft intensity
High pitch Short duration Ex: thigh |
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Percussion notes: intensity, pitch, duration, ex
Hyperresonance... |
Very loud intensity
Lower pitch Longer duration Ex: hyper-inflated lungs of pts w/ COPD or asthma (not a reliable sign) |
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Percussion notes: intensity, pitch, duration, ex
Dullness... |
Medium intensity
Medium pitch Medium duration Ex - liver |
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Percussion notes: intensity, pitch, duration, ex
Resonance... |
Loud intensity
Low pitch Long duration Ex: HEALTHY LUNG |
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Percussion notes: intensity, pitch, duration, ex
Tympany... |
Loud intensity
High pitch - has a musical timbre Ex: gastric air-bubble or puffed out cheek |
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Pathological example of hyperresonance
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COPD, pneumothorax
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Pathological example of dullness
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Consolidated (lobar) PNA
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Pathological example of resonance
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simple chronic bronchitis
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Pathological example of flatness
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large pleural effusion
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Pathological example of tympany
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Lg. pneumothorax
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Dullness replaces resonance in the lungs when ....
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Fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers
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Lobar PNA
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Alveoli are filled with fluid and blood cells
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Pleural effusion
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Pleural accumulations of serous fluid
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Empyema
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Pus in pleural space
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Normal diaphragmatic excursion
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5-6cm
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Abn high diaphragmatic excursion =
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suggestive of pleural effusion, or high diaphragm as in atelectasis or diaphragmatic paralysis
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Most important examination technique for assessing airflow through the tracheobronchial tree
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Auscultation
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Directions for chest auscultation
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Use diaphragm of steth., have pt breathe deeply with open mouth, listen for adventitious sounds and if present perform Transmitted Voice Sound Tests
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Bronchophony
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Louder, clearer voice sounds
Causes: Lobar consolidation |
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Egophony
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Voice sounds w/ a nasal quality, E-A change present
Ex: present in lobar consolidation from PNA |
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Whispered pectoriloquy
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Louder, clearer whispered sounds
Causes: Lobar consolidation |
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Transmitted Voice Sound Tests - when to use, diff. sounds, and what does increased transmission mean?
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- Used if bronchovesicular or bronchial breath sounds are heard in abn locations
- *Increased = suggest that air-filled lung has become airless* - bronchophony, egophony, and whispered pectoriloquy |
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*Vesicular breath sounds
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- Normal
- soft, low pitched - Usually heard over most of both lungs |
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*Bronchial breath sounds
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- Normal
- Louder and higher in pitch - Usually heard over manubrium |
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*Bronchovesicular breath sounds
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- Normal
- Intermediate intensity and pitch - Usually heard over the 1st and 2nd interspaces |
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*Tracheal breath sounds
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- Normal
- Very loud and high pitched - Heard over trachea |
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*If bronchovesicular or bronchial sounds are heard in distant locations, suspect .....
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*air-filled lung has been replaced by fluid or solid tissue mass
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Breath sounds may be decreased:
when air flow is ____ as in ____ or when _______ as in ______ |
When air flow is decreased as in obstructive lung disease or muscular weakness
Or when transmission of sound is poor as in pleural effusion, pneumothorax, or COPD |
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A silent gap b/w inspiratory and expiratory sounds suggests ______
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Bronchial breath sounds
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Types of adventitious sounds
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Crackles (rales), wheezes, and rhonchi
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Crackles (rales): def and causes
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Discontinuous sound, *BRIEF*, Intermittent, Relatively *HIGH PITCHED* sound ("rubbing hair b/w 2 fingers")
Fine: higher pitched, very brief Coarse: louder, lower pitched, brief Causes: PNA, fibrosis, early CHF |
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Persistent crackles (rales) after cough suggests ...
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Lung tissue abnormality
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Wheeze: def and causes
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Continuous, *MUSICAL* sounds, prolonged through respiration, *HIGH PITCHED*, hissing or shrill quality
Causes: narrowed airways as in obstructive disease (asthma, COPD) Can be described as: coarse, diffuse, mild, moderate, or severe |
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Rhonchi: def and causes
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Continuous, *LOW PITCHED*, snoring quality, prolonged through respiration
Causes: secretions in larger airways * May clear w/ cough |
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Friction rub: def and causes
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Continuous sound, loud, grading or squeaking, prolonged
Causes: inflamed pleura w/ loss of lubrication b/w pleura. Pleuritis, PNA, PE |
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Stridor: def and causes
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- Continuous adventitious sound
- Entirely or predominantly inspiratory high-pitched wheeze, often louder in neck - Causes: laryngeal or tracheal obstruction (ominous sign) - Assoc. w/ epiglotitis, laryngeal spasms, foreign body |
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PE findings for asthma
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- If severe, retractions
- Cyanosis, tripod position - *Diminished tactile fremitus* - *Occasional hyper-resonance * - *Wheezing of variable intensity*, rhonchi, prolonged expiration |
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Atelectasis
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Collapse or plugging of airway resulting in obstruction of airflow and lung tissue collapse into airless state
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PE findings for atelectasis
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- Possible tachypnea or diminished chest wall motion (if lobar)
- *Diminished or absent fremitus*, tracheal shift toward involved side - *Dullness over area* - *Diminished or absent breath sounds*, egophony, and whispered pectoriloquy in RUL atelectasis |
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Bronchiectasis: def
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Rare, chronic obstructive lung disease characterized by localized and irreversible dilation or widening of part of the bronchial tree
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Bronchiectasis PE findings
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- Tachypnea, RD, clubbing, cyanosis, wasting
- No unusual percussion findings if no exacerbating cause - * Crackles usually coarse, *rhonchi |
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COPD PE findings
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- Distress, tachypnea, tripod, cyanosis, clubbing, barrel chest
- *Decreased fremitus - *Diffusely hyperresonant - *crackles, wheezes, and rhonchi assoc. w/ bronchitis * |
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Chronic bronchitis PE findings
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- Tachypnea, shallow respirations
- Normal fremitus - **Resonant percussion - Vesicular sounds, *occasional scattered rhonchi, * wheeze, * or coarse crackles (early inspiratory)* |
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L Sided Congestive Heart Failure PE findings
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- Tachypnea, tachycardia, distress, edematous state
- Normal fremitus - *Resonant percussion - *Late inspiratory crackles* (esp bases), possible wheezes, vesicular sounds |
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Pleural effusion: timing, setting, assoc. sx, aggravating factors
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TIming: insidious to rapid
SettingL CHF, malignancy, infections Assoc. sx: dry cough, dyspnea, pleurisy, orthopnea Aggravating factors: exertion and lying flat |
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PE findings for pleural effusion
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- Diminished or delayed wall motion on affected side
- Decreased fremitus - *Dull to flat over fluid* - *Auscultation decreased to absent over fluid, * pleural friction rub, *bronchophony/whispered pectoriloquy |
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PE findings for pneumothorax
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- Tachypnea, cyanosis, distress, *tracheal deviation away from affected area*
- Decreased to absent fremitus - *Hyperresonant - *Decreased to absent auscultation*, possible friction rub |
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Hemothorax: def, timing, setting, assoc. sx, aggravating factors
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Timing: rapid - insidious
Setting: *trauma* to chest or assoc. w/ mass Assoc. sx: SOB, shock, distress, flail chest Aggravating: none specifically |
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Hemothorax PE findings
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- Distress/shock, cyanosis, unequal chest rise, tachypnea, *tracheal deviation away from affected side*
- Decreased or absent fremitus - *Dullness - *Absent or diminished sounds on affected side* |
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TB: def, timing, setting, assoc. sx, aggravating factors
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A granulomatous inflammatory disease d/t infection w/ M. tuberculosis
Timing: insidious Setting: immunocompromised, certain settings, poverty Assoc. sx: * cough, *dyspnea, *night sweats, *fever, *wt loss, *blood tinged sputum * Aggravating: none specifically |
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TB PE findings
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- *Weight loss, clubbing
- Decreased fremitus - Dullness - *Post-tussive rales |
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Pneumonia PE findings
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- Febrile, labored respiration
- *Increased fremitus*, bronchophony, *egophony, and whispered pectoriloquy - *Dull over consolidated area - *Bronchial sounds over consolidated area, *late inspiratory crackles |
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Pulmonary Embolism PE findings
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- Shock, distress, labored respirations, cyanosis
- Palpation and percussion - non-specific - *Decreased sounds |
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Diffuse Interstitial Lung Disease PE findings
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- Inspection: Non-specific unless extra pulmonary signs present. clubbing, cyanosis, barrel chest
- Palpation: none specific to decreased fremitus - Resonance - Non-specific crackles and rhonchi |
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Leading cause of preventable death in US
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*Smoking
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*5 As of smoking
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- *Ask about smoking @ each visit
- *Advise pts to stop smoking - *Assess readiness to quit - *Assist pts by setting stop dates and providing resources -*Arrange f/u visits to monitor and support |
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Lung CA is commonly referred to as ....
Causes, sx |
Bronchogenic carcinoma, CA or bronchial epithelial structures
Causes: smoking, asbestos, radiation, noxious inhaled agents Sx: cough, wheezing, SOB, hemoptysis, DOE, pleurisy, weight loss |
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Hemoptysis in the setting of weight loss is ___ until proven otherwise
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Lung CA
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