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127 Cards in this Set

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Pectus Excavatum
a depression in lower sternum
Pectus Carinatum
An anteriorly displaced sternum
Traumatic flail chest
- Paradoxical mvmts of the thorax that results from multiple rib fractures
- Area injured caves inward during inspiration and outward during expiration
*How to find 2nd rib from suprasternal notch
5cm inferior to sternal angle and laterally
Sternal angle - AKA...
Angle of Loius
*Location for tension pneumothorax needle insertion
*2nd intercostal space
*Location for chest tube insertion
*4th intercostal space (landmark for male nipple)
last rib to articulate with the sternum
7th rib
8th-10th ribs articulate w/ ...
costal cartilages
Floating ribs
11th and 12th, no anterior conenction
*Inferior tip of scapula lies at the level of what rib?
*7th rib/7th interspace
*Location for thoracentesis
*T7-T8 interspace
Apex of the lungs rise _____ above ______
2-4cm above clavicles
Lower border of lung crosses the ____ rib at the midclavicular line
6th rib
Lower border of lung crosses the ____ rib at the midaxillary line
8th rib
Lung bases extend to _____ posteriorly
T10 spinous process
*This spinous process approximates the location of the oblique fissures of the lungs
*T3
*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
*4th rib, 5th rib
Location of trachea bifurcation
@ sternal angle anteriorly, T4 posteriorly
Common complaints regarding chest & lungs
- Chest pain
- SOB
- Wheezing
- Cough
- Hemoptysis
Possible causes of chest pain
- CV
- Pulmonary
- GI
- MSK
- Skin
- Anxiety
Cardiovascular as cause of chest pain.
- Location
Substernal, shoulder, jaw, neck
Cardiovascular as cause of chest pain.
- Quality
- Pressure
- Aching
- Heavy
- "Crushing"
- "Ripping"/"tearing"
- Sharp
Cardiovascular as cause of chest pain.
- Timing
1-20 min
- Intermittent (angina)
- Constant (pericarditis and dissection)
Cardiovascular as cause of chest pain.
- Aggravating factors
- Exertion (angina/MI)
- Breathing and position (pericarditis)
Cardiovascular as cause of chest pain.
- Alleviating factors
- Rest
- Sitting forward (pericarditis)
Cardiovascular as cause of chest pain.
- Associated sx
- Dyspnea
- Nausea
- Diaphoresis (angina/MI)
*Clenched fist over anterior chest, typical in coronary syndrome
*Levine sign
Tracheobronchitis: location, s/s, quality, severity, and a/a factors.
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
Pleuritic pain: location, quality, timing, severity, and aggravating factors
Location: anywhere on the chest wall
Quality: sharp/stabbing
Severity: mod - severe
Timing: constant
Aggravated by: inspiration, coughing/breathing/chest wall motion
Bronchospasm: location, quality, severity, aggravating factors, and assoc. sx
Location: substernal
Quality: sharp - ache
Severity: mild-severe
TIming: episodic
Aggravated by: cough/deep breathing
Assoc. sx: wheezing/dyspnea
GERD: location, quality, severity, and a/a factors
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
Esophageal spasm: location, quality, severity, and a/a factors.
Location: Substernal to jaw or back
Quality: Squeezing
Severity: mild-severe
Aggravated by: swallowing
Alleviated by: occasionally by belching and antacids
Peptic ulcer: location, quality, severity, and alleviating factors
Location: substernal to back/abd
Quality: aching -burning
Severity: mild-severe
Alleviated by: initially may improve w/ food, then will worsen later
Gallbladder: location, quality, severity, a/a factors
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
MSK chest pain: location, quality, severity, timing, aggravating factors, assoc. sx
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
Anxiety as cause of chest pain: location, quality, severity, timing, aggravating factors, assoc. sx
"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
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
Angina pectoris
Temporary myocardial ischemia, usually secondary to coronary atherosclerosis
Pericarditis: location, quality, severity, timing, a/a factors, assoc. sx
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
Dissecting aortic aneurysm: location, quality, severity, timing, a/a factors, assoc. sx
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
Costochondritis: location, quality, severity, timing, a/a factors, assoc. sx
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
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
If pt presents w/ dyspnea, while assessing HPI be sure to
Determine severity based on pt's daily activities
Ie: How many flights of stairs? Walking across room?
MC causes of chest pain in children
Anxiety, costochondritis
SOB assoc. w/ CHF
Orthopnea, DOE, peripheral edema, cough, usually gradual onset but could be sudden in flash edema
Chronic bronchitis: def, timing, a/a factors, assoc. sx, setting
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.
COPD: def, timing, a/a assoc. sx, setting
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
Asthma: def, timing, a/a factors, assoc. sx
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
Left Sided Heart Failure (AKA L Ventricular failure or mitral stenosis): def, timing, a/a factors, assoc. sx
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
Diffuse Interstitial Lung Diseases (ie: sacoidosis, widespread neoplasms, asbestosis, and idiopathic pulmonary fibrosis): timing, a/a factors, assoc. sx
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
Pneumothorax: def.,timing, assoc. sx, setting
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
Pneumonia: def, timing, assoc. sx
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)
PE: def, timing, assoc. sx, aggravating factors, setting
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
Wheezing
- Musical respiratory sound heard w/ inspiration and expiration
- "Accordion sound"
- Typically signifies airway obstruction from secretions, inflammation, or foreign body
Cough: descriptions and causes
- 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
MC cause of acute cough
viral URI
Hemoptysis: origin, color, always concerning sign for ____
- 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
Hemoptysis most often seen in ______
Pts w/ CF
Orthopnea def and common in these pts
- Dyspnea that occurs when pt is lying down and improves when sitting up
- common in CHF pts
PND def
Sudden dyspnea and orthopnea that awakens pt from sleep
Kussmal breathing
deep, labored breathing pattern
Cheyne- Stokes respirations
deep breathing alternating w/ periods of apnea
*Tracheal deviation in pneumothorax
*deviates away from affected side
Retractions of the chest
- Intercostal, during inspiration
- Seen in severe asthma, COPD, or upper airway obstruction
- Most apparent in lower interspaces
Abn chest expansion seen in _____
Fibrosis, pleural effusion, lobal PNA, bronchial obstruction
Fremitus: def, how to test, decreased in ____, increased in_____
*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
Sinus tracts: def, usually indicates, seen in ____
- Blind, inflammatory, tubelike structures opening onto the skin
- Usually indicates inf of underlying pleura and lung
- Seen in TB, actinomycosis
Percussion of chest wall: directions and what will it tell you regarding underlying tissues?
- Use lightest percussion that produces a clear note
- Helps establish whether underlying tissues (5-7cm deep) are air-filled, fluid-filled, or solid
Percussion notes: intensity, pitch, duration, ex
Flatness....
Soft intensity
High pitch
Short duration
Ex: thigh
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)
Percussion notes: intensity, pitch, duration, ex
Dullness...
Medium intensity
Medium pitch
Medium duration
Ex - liver
Percussion notes: intensity, pitch, duration, ex
Resonance...
Loud intensity
Low pitch
Long duration
Ex: HEALTHY LUNG
Percussion notes: intensity, pitch, duration, ex
Tympany...
Loud intensity
High pitch - has a musical timbre
Ex: gastric air-bubble or puffed out cheek
Pathological example of hyperresonance
COPD, pneumothorax
Pathological example of dullness
Consolidated (lobar) PNA
Pathological example of resonance
simple chronic bronchitis
Pathological example of flatness
large pleural effusion
Pathological example of tympany
Lg. pneumothorax
Dullness replaces resonance in the lungs when ....
Fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers
Lobar PNA
Alveoli are filled with fluid and blood cells
Pleural effusion
Pleural accumulations of serous fluid
Empyema
Pus in pleural space
Normal diaphragmatic excursion
5-6cm
Abn high diaphragmatic excursion =
suggestive of pleural effusion, or high diaphragm as in atelectasis or diaphragmatic paralysis
Most important examination technique for assessing airflow through the tracheobronchial tree
Auscultation
Directions for chest auscultation
Use diaphragm of steth., have pt breathe deeply with open mouth, listen for adventitious sounds and if present perform Transmitted Voice Sound Tests
Bronchophony
Louder, clearer voice sounds
Causes: Lobar consolidation
Egophony
Voice sounds w/ a nasal quality, E-A change present
Ex: present in lobar consolidation from PNA
Whispered pectoriloquy
Louder, clearer whispered sounds
Causes: Lobar consolidation
Transmitted Voice Sound Tests - when to use, diff. sounds, and what does increased transmission mean?
- 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
*Vesicular breath sounds
- Normal
- soft, low pitched
- Usually heard over most of both lungs
*Bronchial breath sounds
- Normal
- Louder and higher in pitch
- Usually heard over manubrium
*Bronchovesicular breath sounds
- Normal
- Intermediate intensity and pitch
- Usually heard over the 1st and 2nd interspaces
*Tracheal breath sounds
- Normal
- Very loud and high pitched
- Heard over trachea
*If bronchovesicular or bronchial sounds are heard in distant locations, suspect .....
*air-filled lung has been replaced by fluid or solid tissue mass
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
A silent gap b/w inspiratory and expiratory sounds suggests ______
Bronchial breath sounds
Types of adventitious sounds
Crackles (rales), wheezes, and rhonchi
Crackles (rales): def and causes
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
Persistent crackles (rales) after cough suggests ...
Lung tissue abnormality
Wheeze: def and causes
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
Rhonchi: def and causes
Continuous, *LOW PITCHED*, snoring quality, prolonged through respiration
Causes: secretions in larger airways
* May clear w/ cough
Friction rub: def and causes
Continuous sound, loud, grading or squeaking, prolonged
Causes: inflamed pleura w/ loss of lubrication b/w pleura. Pleuritis, PNA, PE
Stridor: def and causes
- 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
PE findings for asthma
- If severe, retractions
- Cyanosis, tripod position
- *Diminished tactile fremitus*
- *Occasional hyper-resonance *
- *Wheezing of variable intensity*, rhonchi, prolonged expiration
Atelectasis
Collapse or plugging of airway resulting in obstruction of airflow and lung tissue collapse into airless state
PE findings for atelectasis
- 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
Bronchiectasis: def
Rare, chronic obstructive lung disease characterized by localized and irreversible dilation or widening of part of the bronchial tree
Bronchiectasis PE findings
- Tachypnea, RD, clubbing, cyanosis, wasting
- No unusual percussion findings if no exacerbating cause
- * Crackles usually coarse, *rhonchi
COPD PE findings
- Distress, tachypnea, tripod, cyanosis, clubbing, barrel chest
- *Decreased fremitus
- *Diffusely hyperresonant
- *crackles, wheezes, and rhonchi assoc. w/ bronchitis *
Chronic bronchitis PE findings
- Tachypnea, shallow respirations
- Normal fremitus
- **Resonant percussion
- Vesicular sounds, *occasional scattered rhonchi, * wheeze, * or coarse crackles (early inspiratory)*
L Sided Congestive Heart Failure PE findings
- Tachypnea, tachycardia, distress, edematous state
- Normal fremitus
- *Resonant percussion
- *Late inspiratory crackles* (esp bases), possible wheezes, vesicular sounds
Pleural effusion: timing, setting, assoc. sx, aggravating factors
TIming: insidious to rapid
SettingL CHF, malignancy, infections
Assoc. sx: dry cough, dyspnea, pleurisy, orthopnea
Aggravating factors: exertion and lying flat
PE findings for pleural effusion
- 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
PE findings for pneumothorax
- Tachypnea, cyanosis, distress, *tracheal deviation away from affected area*
- Decreased to absent fremitus
- *Hyperresonant
- *Decreased to absent auscultation*, possible friction rub
Hemothorax: def, timing, setting, assoc. sx, aggravating factors
Timing: rapid - insidious
Setting: *trauma* to chest or assoc. w/ mass
Assoc. sx: SOB, shock, distress, flail chest
Aggravating: none specifically
Hemothorax PE findings
- 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*
TB: def, timing, setting, assoc. sx, aggravating factors
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
TB PE findings
- *Weight loss, clubbing
- Decreased fremitus
- Dullness
- *Post-tussive rales
Pneumonia PE findings
- Febrile, labored respiration
- *Increased fremitus*, bronchophony, *egophony, and whispered pectoriloquy
- *Dull over consolidated area
- *Bronchial sounds over consolidated area, *late inspiratory crackles
Pulmonary Embolism PE findings
- Shock, distress, labored respirations, cyanosis
- Palpation and percussion - non-specific
- *Decreased sounds
Diffuse Interstitial Lung Disease PE findings
- Inspection: Non-specific unless extra pulmonary signs present. clubbing, cyanosis, barrel chest
- Palpation: none specific to decreased fremitus
- Resonance
- Non-specific crackles and rhonchi
Leading cause of preventable death in US
*Smoking
*5 As of smoking
- *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
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
Hemoptysis in the setting of weight loss is ___ until proven otherwise
Lung CA