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101 Cards in this Set

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What are the major components of the chest anatomy?
- Manubrium
- Suprasternal notch
- Sternal angle (angle of Louis)
- 1st and 2nd ribs
- Xyphoid process
- Manubrium
- Suprasternal notch
- Sternal angle (angle of Louis)
- 1st and 2nd ribs
- Xyphoid process
Pectus excavatum
Depression in the lower sternum
Depression in the lower sternum
Pectus carinatum
Anteriorly displaced sternum
Anteriorly displaced sternum
Traumatic flail chest
Multiple rib fractures resulting in paradoxical movements of the thorax. 
On inspiration, injured area caves inward and expiration outward
Multiple rib fractures resulting in paradoxical movements of the thorax.
On inspiration, injured area caves inward and expiration outward
Thoracic kyphoscoliosis
Abnormal spine curve and vertebral rotation causing chest deformities.
Abnormal spine curve and vertebral rotation causing chest deformities.
How to palpate 2nd rib
From suprasternal notch, move about 5 cm inferiorly to the sternal angle and then laterally (start counting interspaces).
Where is a tension pneumothorax needle inserted?
2nd intercostal space
Where is a chest tube inserted?
4th intercostal space
Where do ribs articulate?
7th rib - last to articulate with sternum
8-10th ribs - articulate with costal cartilage
11th and 12th ribs - free floating
How do you palpate the 12th rib?
Palpable posteriorly and can start counting ribs/interspaces
Where is a thoracentesis performed?
T7-T8 interspace

Palpate the inferior tip of scapula, which lies at the level of the 7th rib/interspace.
How do you palpate C7?
With neck flexed, the most protruding process is usually C7.
How to describe locations on the chest
Vertical axis – note rib level by counting ribs

Circumference around the chest – bony landmarks and vertical lines
Vertical lines on chest
- Midsternal line
- Midclavicular line (near nipple line)
- Axillary lines (anterior, midaxillary, posterior axillary) - Vertebral line
- Scapular line
- Midsternal line
- Midclavicular line (near nipple line)
- Axillary lines (anterior, midaxillary, posterior axillary) - Vertebral line
- Scapular line
Where is the apex of lung located?
Rises 2-4 cm above clavicles
Rises 2-4 cm above clavicles
Where is the base of the lung located?
Extends
- 6th rib midclavicular
- 8th rib midaxillary
- T10 spinous process posteriorly
Extends
- 6th rib midclavicular
- 8th rib midaxillary
- T10 spinous process posteriorly
Where is oblique fissure of lung located?
Near the spinous process of T3.
Near the spinous process of T3.
Where is horizontal fissure of lung located?
Near 4th rib to midaxillary line near 5th rib.

On right chest, must listen to the lateral chest for right lower lobe (RLL) sounds.
Near 4th rib to midaxillary line near 5th rib.

On right chest, must listen to the lateral chest for right lower lobe (RLL) sounds.
Where is the tracheal bifurcation located?
At sternal angle anteriorly and T4 posteriorly.
Common chest complaints
- Chest pain
- Shortness of breath
- Wheezing
- Cough
- Hemoptysis (coughing up blood)
Possible causes of chest pain
- Cardiovascular
- Pulmonary
- GI
- Musculoskeletal
- Skin
- Anxiety
... and others
Location of cardiovascular chest pain
- Substernal
- Shoulder
- Jaw
- Neck
Quality of cardiovascular chest pain
- Pressure
- Ache
- Heavy
- Crushing
- Ripping or tearing
- Sharp
Quantity of cardiovascular chest pain
Mild to severe (typically more significant)
Timing of cardiovascular chest pain
- 1-20 min and intermittent (angina)
- Constant (pericarditis and dissection)
Aggravating factors related to cardiovascular chest pain
- Exertion (angina/MI)
- Breathing and position (pericarditis)
Alleviating factors related to ardiovascular chest pain
Rest, sitting forward (pericarditis)
Associated symptoms of cardiovascular chest pain
Dyspnea, nausea, diaphoresis (angina/MI)
Levine sign
A clenched fist over the anterior chest, typical in coronary syndrome.
Tracheobronchitis presentation
May be related to flu, upper chest, burning, mild-moderate, aggravated by cough/deep breathing, alleviated by lying on involved side
Pleuritic pain presentation
Any chest wall area, sharp/stabbing, mod-severe, constant, aggravated by cough/breathing/chest wall motion
Bronchospasm presentation
Substernal, sharp to ache, mild-severe, episodic, aggravated by cough/breathing deep, associated with wheezing/dyspnea
GERD presentation
Substernal and to back, burning/squeezing, mild-severe, worse after meals and lying down, alleviated with antacids (some)
Esophageal spasm presentation
Substernal to jaw or back, squeezing, mild-severe, aggravated with swallowing, improved occasionally with belching and antacids
Peptic ulcer presentation
Substernal to back/abdomen, ache to burn, mild-severe, initially may improve with food then worsen later
Gallbladder disease presentation
Substernal to back/abdomen, ache to burn, mild-severe, initially may improve with food then worsen later, worse with greasy meals.
Musculoskeletal chest pain
Any location on chest wall, stabbing to aching, mild-severe, lasts hours to days constant to variable, aggravated by chest motion, tender over area
Anxiety pain
Any chest wall location, ache-dull-sharp-pressure, mild-severe, variable timing usually hours-days, may follow emotion stress event (but not always)
Possible causes of shortness of breath (dyspnea)
Congestive heart failure
COPD/Chronic bronchitis
Asthma
Interstitial lung disease
Pneumonia
Pneumothorax
Pulmonary embolism (blood clot)
Anxiety
Other: GERD (causes lung spasms), obesity, etc…
Wheezing
Musical respiratory sound heard with inspiration and expiration “accordion sound.”

Cause: airway obstructive from secretions, inflammation, or foreign body
Cough
Dry or productive

Cause: irritant as in mucus, pus, blood, dust, foreign bodies, heat/cold, medication (Mucinex, ACE inhibitors), other
Hemoptysis
Coughing up blood from lungs (blood > mucus)
Typically bright red or rust colored
Consider neoplasm until proven otherwise
Always quantify amount and frequency and last episode

Causes: infection, lung cancer, CHF, PE, irritant, could be postnasal, mouth, pharynx, or GI source
Stridor
Audible high pitched wheezed, ominous sign of airway obstruction in the larynx or trachea.

Cause: epiglottitis, laryngeal spasm, foreign body
Orthopnea
Dyspnea that occurs when patient is lying down and improves with sitting up.

Common in CHF
Paroxysmal nocturnal dyspnea
Sudden dyspnea and orthopnea that awakens the patients from sleep.
Tachypnea/Bradypnea
Fast/slow respiratory rate
Kussmal breathing
Deep, labored breathing pattern
Cheyne Stokes respirations
Deep breathing alternating with periods of apnea
Chest inspection
Inspect:
- Rate, rhythm, depth and effort of breathing
- Signs of distress
- Skin color (cyanosis)
- Stridor/wheezing
- Chest movements
- Chest diameter (larger in COPD)
- Retractions (supraclavicular)
- Tracheal deviations (indicates pneumothorax)
Chest palpation
Palpate:
- Painful areas (put finger on area of pain)
- Masses
- Test chest expansion
- Feel for tactile fremitus
How to test chest expansion
Test anteriorly with thumbs along costal margin

Test posteriorly with thumbs at T10 

Watch the distance between the thumbs during inspiration and feel for symmetry

Causes of abnormal expansion:
- Unilateral decrease or delay in fibrosis
...
Test anteriorly with thumbs along costal margin

Test posteriorly with thumbs at T10

Watch the distance between the thumbs during inspiration and feel for symmetry

Causes of abnormal expansion:
- Unilateral decrease or delay in fibrosis
- Pleural effusion
- Lobar pneumonia
- Bronchial obstruction
Tactile fremitus
Palpable vibrations transmitted through the bronchopulmonary tree to the chest wall.
How to feel for tactile fremitus
Ask patient to repeat words “99” or “1-1-1," while using bony part of palm or ulnar surface of hand and compare symmetry of left to right.

Decreased when transmission of vibrations from the larynx to chest is impeded. 
Causes of decrease...
Ask patient to repeat words “99” or “1-1-1," while using bony part of palm or ulnar surface of hand and compare symmetry of left to right.

Decreased when transmission of vibrations from the larynx to chest is impeded.
Causes of decreased transmission
- Chest wall size (barrel chest)
- Obstructed bronchus
- COPD
- Pleural effusion
- Fibrosis
- Pneumothorax
- Tumor

Causes of increased transmission
- Unilateral pneumonia
Chest percussion
- Perform side to side to assesses for asymmetry
- Test extent of diaphragmatic excursion
- Locate upper border of liver
How to percuss chest
- Perform from side to side to assess for asymmetry
- Strike using the tip of your tapping finger
- Use lightest percussion that produces a clear note

Percussion establishes whether underlying tissues (5-7 cm deep) are air-filled, fluid-fille...
- Perform from side to side to assess for asymmetry
- Strike using the tip of your tapping finger
- Use lightest percussion that produces a clear note

Percussion establishes whether underlying tissues (5-7 cm deep) are air-filled, fluid-filled, or solid

Percussion notes
- Flatness (soft)
- Dullness (medium)
- Resonance (loud)
- Hyperresonance (very loud)
- Tympany (loud)
How to test diaphragmatic excursion
Find level of diaphragmatic dullness during quiet respiration – percuss downward until dullness replaces resonance, confirm laterally and medially. 

Estimate the extent of diaphragmatic excursion by determining the distance between the level ...
Find level of diaphragmatic dullness during quiet respiration – percuss downward until dullness replaces resonance, confirm laterally and medially.

Estimate the extent of diaphragmatic excursion by determining the distance between the level of dullness on full expiration and the level of dullness on full inspirations (normal 5-6cm).

Abnormal high level causes
- Pleural effusion, atelectasis or diaphragmatic paralysis
Chest Auscultation
Most important exam technique for assessing air flow through the tracheobronchial tree.

Together with percussion, it helps to assess the condition of surrounding lungs and pleural space.

Listen to the breath sounds with the diaphragm of a st...
Most important exam technique for assessing air flow through the tracheobronchial tree.

Together with percussion, it helps to assess the condition of surrounding lungs and pleural space.

Listen to the breath sounds with the diaphragm of a stethoscope after instructing the patient to breathe deeply through an open mouth.

Use the pattern suggested for percussion, moving from one side to the other and comparing symmetric areas of the lungs.

Listen to at least one full breath in each location.
How to auscultate the chest
Always listen to bare skin (not through clothing or gowns which can generate confusion sounds)
Listen to sounds generated by breathing
Listen for adventitious sounds (added)
- timing, location, persistence
Transmitted Voice Sound Tests
- Bronchophony
- Egophony
- Whispered pectoriloquy
Vesicular breath sounds
Soft and low pitched
Usually heard over most of both lungs
Bronchial breath sounds
Louder and higher in pitch
Usually heard over the manubrium

Bronchovesicular or bronchial sounds heard in distant locations, suspect air-filled lung replaced by fluid or solid tissue mass.
Bronchovesicular
Intermediate intensity and pitch
Usually heard over the 1st and 2nd interspaces

Bronchovesicular or bronchial sounds heard in distant locations, suspect air-filled lung replaced by fluid or solid tissue mass.
Tracheal
Very loud, high pitched
Heard over the trachea in the neck
Types of adventitious sounds
Discontinuous sounds
- Crackles

Continuous sounds
- Wheeze
- Rhonchi
- Friction rub
- Stridor
Asthma
Airways characterized by variable and reversible inflammation, mucous plugging, and bronchial smooth muscle constriction.
Clinical presentation of asthma
Timing - acute onset with symptom free periods, nocturnal symptoms are most common.

Symptoms - cough, shortness of breath, wheezing, tightness

Aggravating factors - allergens, irritants, infections, stress
Physical exam findings of asthma
Inspection - respiratory retractions if severe, cyanosis, tripod position

Palpation - diminished tactile fremitus

Percussion - occasional hyper-resonance

Auscultation - wheezing of variable intensity, rhonchi, prolonged expiration
Atelectasis
A collapse or plugging of the airway resulting in obstruction of airflow and lung tissue collapse into an airless state.
Physical exam findings of atelectasis
Inspection - possible tachypnea and diminished chest wall motion (if lobar)

Palpation - diminished or absent fremitus, tracheal shift toward involved side

Percussion - dullness over area

Auscultation - diminished or absent breath sounds, egophony and whispered pectoriloquy in RUL atelectasis
Bronchiectasis
A rare chronic obstructive lung disease characterized by localized and irreversible dilation or widening of part of the bronchial tree.

Tissues don't move well, can't get CO2 out effectively.
Physical exam findings of bronchiectasis
Inspection - tachypnea, respiratory distress, clubbing, cyanosis, wasting

Palpation - no consistent findings

Percussion - no unusual findings if no exacerbating cause (pneumonia)

Auscultation - crackles usually coarse, rhonchi
Chronic Obstructive Lung Disease (COPD)
Characterized by over-distention of air spaces distal to terminal bronchioles, with destruction of alveolar septa and airway obstruction (generic term for a broad category of conditions).

Includes emphysema and chronic bronchitis.
Clinical presentation of COPD
Timing - slow progressive dyspnea and cough

Setting - history of smoking or pollutants, familial deficiency in alpha1 antitrypsin

Symptoms - cough, dyspnea, scant mucous production

Aggravating factors - exertion, infections
Physical exam findings of COPD
Inspection - distress, tachypnea, tripod, cyanosis, clubbing, barrel chest

Palpation - decreased fremitus

Percussion - diffusely hyperresonant

Auscultation - crackles, wheezes and rhonchi associated with bronchitis
Chronic bronchitis
A chronic obstructive disease characterized by inflammation of the bronchi, mucous production, and cough.
Clinical presentation of chronic bronchitis
Timing - slow progressive dyspnea

Setting - history of smoking or pollutant exposure

Symptoms - chronic productive cough, wheezing, recurrent infections

Aggravating - infections, exertion, irritants, smoking
Physical exam findings of chronic bronchitis
Inspection - tachypnea, shallow respirations

Palpation - normal fremitus

Percussion - resonant

Auscultation - vesicular sounds, occasional scattered rhonchi, wheeze, or coarse crackles (early inspiratory)
Left-sided congestive heart failure
Failure of the heart pump function resulting in increased pressure in the pulmonary veins causing congestion and interstitial edema.
Clinical presentation of CHF
Timing - progressive dyspnea or sudden pulmonary edema

Setting - history of heart disease or predisposing factors

Associated symptoms - cough, orthopnea, paroxysmal nocturnal dyspnea (PND), occasional wheezing

Aggravating factors - exertion, lying flat
Physical exam findings of CHF
Inspection - tachypnea, tachycardia (CO=HRxSV), distress, edematous state

Palpation - normal fremitus

Percussion -resonant

Auscultation - late inspiratory crackles (especially bases), possible wheezes, vesicular sounds
Pleural effusion
Fluid accumulation in the pleural space which separates air filled lung from the chest wall.
Fluid accumulation in the pleural space which separates air filled lung from the chest wall.
Clinical presentation of pleural effusion
Timing - insidious to rapid

Setting - congestive heart failure, malignancy, infectious

Associated symptoms - dry cough, dyspnea, pleurisy, orthopnea

Aggravating factors - exertion and lying flat
Physical exam findings of pleural effusion
Inspection - diminished or delayed wall motion on affected side

Palpation - decreased fremitus

Percussion - dull to flat over fluid

Auscultation - decreased to absent over fluid, pleural friction rub, bronchophony/whispered pectoriloquy
Inspection - diminished or delayed wall motion on affected side

Palpation - decreased fremitus

Percussion - dull to flat over fluid

Auscultation - decreased to absent over fluid, pleural friction rub, bronchophony/whispered pectoriloquy
Pneumothorax
Condition when air leaks into the pleural space, usually unilateral. 

Tension – when pneumothorax leads to significant respiratory and circulatory impairment (emergency)

Spontaneous – primary or secondary types
Condition when air leaks into the pleural space, usually unilateral.

Tension – when pneumothorax leads to significant respiratory and circulatory impairment (emergency)

Spontaneous – primary or secondary types
Clinical presentation of pneumothorax
Timing - rapid onset

Setting - trauma, chronic lung disease, surgery, tall, thin male

Associated symptoms - dyspnea, respiratory distress, pleurisy

Aggravating factors - exertion
Physical exam findings of pneumothorax
Inspection - tachypnea, cyanosis, distress, tracheal deviation away from pneumothorax

Palpation - decreased to absent fremitus	

Percussion - hyperresonant 

Auscultation - decreased to absent, possible friction rub

X-ray - dark space is...
Inspection - tachypnea, cyanosis, distress, tracheal deviation away from pneumothorax

Palpation - decreased to absent fremitus

Percussion - hyperresonant

Auscultation - decreased to absent, possible friction rub

X-ray - dark space is a pneumothorax
Hemothorax
A condition in which blood accumulates in the pleural cavity, typically associated with trauma or malignancy.
Clinical presentation of hemothorax
Timing - rapid to insidious

Setting - trauma to the chest or associated with mass

Associated symptoms - shortness of breath, shock, distress, flail chest

Aggravating factors - none specific
Physical exam findings of hemothorax
Inspection - distress/shock, cyanosis, unequal chest rise, tachypnea, tracheal deviation away from affected side

Palpation - decreased or absent fremitus

Percussion - dullness over area

Auscultation - absent or diminished sounds on affected side
Tuberculosis
A granulomatous inflammatory disease due to infection with mycobacterium tuberculosis.
Clinical presentation of TB
Timing - insidious

Setting - Immune illness (HIV), exposure to locations, poverty

Associated symptoms - cough, dyspnea, night sweats, fever, weight loss, blood tinged sputum
Physical exam findings of TB
Inspection - weight loss, clubbing

Palpation - decreased fremitus

Percussion - dullness

Auscultation - post-tussive rales
Pneumonia
Infection and inflammation of the parenchyma from the bronchioles to the alveoli.
Clinical presentation of pneumonia
Timing - acute illness, onset varies with cause

Setting - varied

Associated symptoms - cough, sputum production, fever, pleuritic pain

Aggravating factors - none specific
Physical exam finding of pneumonia
Inspection - febrile, distress, labored respiration

Palpation - increased fremitus, bronchophony, egophony, and whispered pectoriloquy

Percussion - dull over consolidated area

Auscultation - bronchial sounds over consolidated area, late inspiratory crackles
Diffuse interstitial lung disease (ILD)
Abnormal widespread infiltration of cells, fluid, and collagen into interstitial spaces between alveoli

Includes sarcoidosis, asbestosis, cystic fibrosis and pulmonary fibrosis.
Clinical presentation of ILD
Timing - progressive dyspnea varies with cause

Setting - varied on cause (occupational exposure, familial)

Associated symptoms - weakness, fatigue, minimal cough, hemoptysis

Aggravating factors - exertion
Physical exam findings of ILD
Inspection - non specific unless extra pulmonary signs present, clubbing, cyanosis, barrel chest

Palpation - non specific to decreased fremitus

Percussion - resonant

Auscultation - non specific crackles and rhonchi
What is the leading cause of preventable death in the US?
Tobacco abuse
What steps in an H&P should you take regarding tobacco abuse?
Remember the 5 “A”s
Ask about smoking at each visit

Advise patients regularly to stop smoking using a clear, personalized message – be sure to document

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

No screening for lung cancer is recommended.
Lung cancer
Generally referring to bronchogenic carcinoma, cancer of the bronchial epithelial structures. 

Causes - tobacco, asbestos, radiation, and noxious inhaled agents
Generally referring to bronchogenic carcinoma, cancer of the bronchial epithelial structures.

Causes - tobacco, asbestos, radiation, and noxious inhaled agents
Symptoms of lung cancer
Cough
- Wheezing
- Shortness of breath (SOB)
- Hemoptysis
- Dizziness on exertion (DOE)
- Pleurisy
- Weight loss

Hemoptysis in the setting of weight loss and cough is lung cancer until proven otherwise.
Cough
- Wheezing
- Shortness of breath (SOB)
- Hemoptysis
- Dizziness on exertion (DOE)
- Pleurisy
- Weight loss

Hemoptysis in the setting of weight loss and cough is lung cancer until proven otherwise.