advanced physical assessment - The Thorax and Lungs

when percussing the lungs, when does unilateral hyperresonance replace resonance?

Unilateral hyperresonance suggests a large pneumothorax or an air-filled bulla.

When percussing, where would a normal finding of a hyperresonant note be found?

Usually none

What normal breath sound is this: soft and low pitched.

Vesicular

Wheezing is what part of the breathing cycle?

Wheezes can be inspiratory, expiratory, or biphasic (continuous).

When does wheezing occur?

Wheezing occurs in partial lower airway obstruction from secretions and tissue inflammation in asthma, or from a foreign body

Retraction occurs when?

in severe asthma, COPD, or upper airway obstruction.

When percussing, where would a normal finding of a dull note be found?

liver

what is the location of pain in Myocardial Infarction?

location: Retrosternal or across the anterior chest, often radiates to the shoulders, arms, neck, lower jaw, or upper abdomen (same as angina)

a finger pointing to a tender spot on the chest wall suggests

musculoskeletal pain

Comorbidities seen with sleep apnea?

obesity, posterior malocclusion of the jaw (retrognathia), treatment-resistant hypertension, heart failure, atrial fibrillation, stroke, and type 2 diabetes.

_____ is an audible high-pitched inspiratory whistling. what is its implications?

or stridor, is an ominous sign of upper airway obstruction in the larynx or trachea that requires urgent airway evaluation.

Accessory muscle use signals difficulty breathing frOM:

COPD or respiratory muscle fatigue.

Lateral displacement of the trachea occurs in:

pneumothorax, pleural effusion, and atelectasis

What are the characteristics of mucoid sputum and when is it seen?

translucent, white, or gray and seen in viral infections and cystic fibrosis;

1. The nurse is helping a community prevent an outbreak of streptococcal pneumonia. She performs vaccinations on different age groups in all walks of life. Which of the following patients is the vaccine highly recommended to be administered to? a. A 35-year old female teacher with hoarseness of the voice b. A 26-year old male soccer player with a pulled muscle c. A 46-year old bank executive with vitiligo d. A 23-year old new employee about to receive a cochlear implant

ANs: (D) The pneumococcal vaccine is highly recommended for the following risk groups: 65 years old and older, those with chronic illnesses aged 2-64, anyone about to receive a cochlear implant, the immunocompromised, and healthy children older than 6 months.

1. The nurse is assessing the oxygen saturation of a woman who just underwent normal delivery. Her delivery was uneventful. Her vital signs are normal. Upon checking her pulse oximeter, she got a reading of 66%. To which factor can the nurse attribute the reading? a. Too much ambient light b. Malfunction of the oximeter c. Pulse oximeter has slid out of her finger d. Pulse oximeter is slid under her thumb

Ans: (A) Certain factors affect pulse oximeter readings such as ambient light, hemoglobin and blood volume deficiencies, patient movement, strong electromagnetic fields, irregular heartbeats, nail polish, dark skin pigmentation and intravenous dyes.

Which of the following is a normal finding when assessing the respiratory system of an emphysema client? a. A increased anteroposterior diameter and low inspiratory and expiratory ratio b. Audible breath sounds without auscultation c. Increased chest expansion d. Flatness on percussion

Ans: (A) Emphysema is a chronic obstructive pulmonary disease characterized by an increased in anteroposterior diameter caused by permanent enlargement of the airspaces distal to the bronchioles secondary to decreased elastin in the lungs. With decreased elasticity, the lungs are in constant hyper aerated state, accumulating carbon dioxide. In an attempt to excrete the carbon dioxide, the patent exhales longer than normal, accounting for the lower I:E ratio.

1. The nurse is assessing a client with emphysema. How would the client most likely describe his dyspnea? a. Slowly progressive b. Acute episodes, separated by symptom-free periods. c. Sudden onset d. Episodic

Ans: (A) Emphysema is a progressive disease wherein symptoms gradually worsen over time. The nurse expects that the client will report difficulty breathing that worsens over months or years.

1. A nursing supervisor instructs a new nurse to watch out for intercostal retraction on a 1-year old patient. Which of the following describes intercostal retraction accurately? a. The muscles between the ribs are pulled inward as the client inhales b. The diaphragm expands during expiration c. The chest expands on one side only d. The muscles between the ribs puff as the client inhales.

Ans: (A) Intercostal retractions are the inward movement of the intercostal muscles, the muscles between the ribs during inhalation. These are caused by blockage of the airways.

1. The nurse is auscultating the lungs of a patient and hears bronchovesicular sounds at the base of the right lungs. Which of the following is an accurate interpretation of your findings? a. It is expected and is normal b. It may suggest fluid or mass in the right lower lobe c. It suggests atelectasis of the right lower lobe d. The client must be positioned on his left before auscultation

Ans: (B) Bronchovesicular sounds are breath sounds heard best in the first and second intercostal space anteriorly and between the scapulae. In these locations, the inspiration and expiration sounds are about equal. If heard in the lower areas, it may indicate fluid or mass occupying the lobe/s.

1. A new nurse is performing a complete physical examination of a client suspected of having a lung tumor. She understands that, in assessing for fremitus, the nurse's hands should be positioned a. Cupped over the lower back b. Flat and touching the lower back c. Fisted and touching the front of the chest d. Level to the heart, and finger pads touching the back

Ans: (B) In assessing for fremitus, the both hands should be flat on the back or front of the chest to efficiently feel vibrations as the client speaks.

1. A client comes to the clinic with difficulty of breathing. He reports that sometimes, he wakes up at night gasping for air. He added that he has to prop himself up with 2 pillows to be able to sleep without breathing difficulty. The nurse assesses fremitus, and understands that which of the following conditions will the nurse probably feel a decrease in fremitus? a. Pneumonia b. Pleural effusion c. Lung tumor or mass d. Pulmonary fibrosis

Ans: (B) In cases where the lungs are filled with fluid (e.g. pleural effusion) or air or are vacant, the fremitus is decreased. The signs and symptoms of the client are characteristic of pleural effusion. Fremitus is increased in conditions that will have consolidations in the lungs such as pneumonia or in lung tumor and fibrosis.

1. A nurse admits a client in the emergency department after a vehicular accident. He complains of pain and is having difficulty in breathing. He is also diaphoretic. The nurse observes his chest and notes paradoxical chest movement. Which is an accurate description of paradoxical chest movement? a. The chest expands on the unaffected side only b. The flail part of the chest is sucked in on inspiration and bulges during expiration c. The flail part of the chest bulges on inspiration and is sucked in during expiration d. The intercostal muscles move inward during inspiration

Ans: (B) Paradoxical chest movement happens when the flail part of the chest is sucked in on inspiration and bulges during expiration. This happens when fractured ribs cannot simultaneously move with the rest of the chest.

A community health nurse is doing her rounds in the neighborhood when she was suddenly summoned by a frantic mother whose 1-year old child appears to be in distress. The mother says that her child is making strange noises as she breathes. Upon assessment, the nurse hears a high-pitched sound during inspiration. This alerts the nurse to which finding? a. Wheeze b. Stridor c. Rales d. Ronchi

Ans: (B) Stridor is a loud, harsh, high pitched respiratory sound caused by obstruction of the larger airways (trachea, larynx or pharynx). A wheeze is a coarse whistling sound heard during expiration. Rales are small clicking, bubbling, or rattling sounds in the lungs heard during inhalation. Ronchi are low pitched, snore-like sounds and are caused by airway secretions and airway narrowing.

1. A nurse is caring for a client with complete atelectasis of the lower lobe of the left lung. Which assessment finding is most accurate? a. Absent breath sounds on the left side of the chest b. Dullness over the left lower chest on percussion c. Bronchovesicular sounds heard over the lower chest on auscultation d. Increased fremitus over the entire chest area

Ans: (B) Atelectasis is collapse of the lung or part of the lungs due to obstruction or a mucus plug in the airways. There is dullness on the airless area, absent breath sounds on the affected part (with the exception of the right upper lobe where tracheal sounds are still apparent) and absent fremitus (increased in upper right lobar atelectasis).

1. A client is developing complications of pneumonia. Which characteristics of chest pain would alert the nurse to the possibility of pleurisy? a. Pressing, squeezing sensation relieved by rest b. Burning pain and lying on the involved side relieves it c. Sharp, knife-like, worsened by movement and inspiration d. Pressing, squeezing sensation unrelieved by rest

Ans: (C) Chest pain in pleurisy is described as a sharp and knife-like and is worsened by movement and inspiration. Burning pain and the consequent relief when lying on the affected side describe chest pain in tracheobronchitis. Pain that is pressing, squeezing is of cardiac origin. If the chest pain is relieved by rest it is caused by angina pectoris. If the pain persists and unrelieved by rest, it is caused by myocardial infarction.

1. A nurse hears fine crackling sounds in the client's lungs upon auscultation. The client complains that he is catching up on his breaths and is feeling really tired. Which of the following clients is the nurse most probably assessing? The client with a. Upper respiratory tract infection b. Asthma c. Congestive heart failure d. Pneumothorax

Ans: (C) Rales are fine non-musical crackling sounds when small airways blocked by fluid open as one inhales. It is heard in pneumonia, fibrosis, early congestive heart failure, bronchitis, bronchiectasis and pulmonary edema.

1. The nurse admits a client with left-sided heart failure secondary to mitral stenosis in the intensive care unit. He had developed pulmonary edema and is for constant monitoring. The nurse understands that which characteristics of the client's sputum is the nurse most likely to observe? a. Greenish, mucoid, sticky b. Red, jelly-like c. Pinkish tinged, frothy d. Foul-smelling purulent

Ans: (C) The client with pulmonary edema will have pink frothy sputum. The pinkish tinge is due blood coming from minute capillaries erupting, and the fine bubbles that makes it frothy is created by air trying to escape from the fluid-filled alveolar bed.

1. A client obtained a traumatic sports injury to the chest. He was admitted to be treated for pleural effusion. Which of the following assessment findings would necessitate the nurse to promptly inform the physician of the client's condition? a. Decreased breath sounds on the affected side b. A pleural rub on auscultation c. Minimal tracheal deviation to the unaffected side d. Pain on the affected side

Ans: (C) Tracheal deviation in a client with pleural effusion is a medical emergency. It signifies that the effusion has gotten so large that it pushes the lungs and mediastinal organs to the unaffected side. All other assessment findings in A, B and D are expected.

1. The nurse is auscultating the lungs of the patient. In an otherwise healthy patient, what type of breath sounds are expected to be heard over the 3rd intercostal space and lower in the lung fields? a. Bronchial b. Bronchovesicular c. Vesicular d. Crackles

Ans: (C) Vesicular breath sounds are soft, relatively low-pitched sounds heard over most of the lung fields lower than the 2ndintercostal space.

1. A client involved in a car crash is admitted due to chest injuries. Upon auscultation, the nurse notes fine creaking sounds confined to a small area of impact and is heard on both inspiration and expiration. The sound can be sometimes heard continuously. The nurse hears which kind of adventitious sounds? a. Stridor b. Ronchi c. Crackles d. Pleural rub

Ans: (D) A pleural rub is a fine creaking sound heard over a small area of the lungs and is heard on both inspiration and expiration, and sometimes heard continuously in both phases of respiration. It is produced by the inflamed and roughened pleura rubbing against each other.

1. A 65-year old patient is admitted to the emergency department with a chief complaint of ripping chest pain after accidentally being hit on the chest with a ball. His medical records show that he has chronic hypertension. The nurse is quick to institute measures to care for a patient with which condition? a. Myocardial infarction b. Pericarditis c. Endocarditis d. Dissecting aortic aneurysym.

Ans: (D) In a dissecting aortic aneurysm, the aorta (usually the thoracic artery) gets torn from the inside. The tear allows blood to seep between the layers of the aorta causing it to bulge and most likely rupture. It causes decreased blood flow to the lower parts of the body and produces severe ripping pain. It is considered a medical emergency.

1. A nurse admits a client with chills, high fever and dyspnea. His blood works states that he has a high level of alcohol in his blood. He is also expectorating red, sticky and jelly-like sputum. The nurse attributes the signs and symptoms to which disorder? a. Tuberculosis b. Lung abscess c. Laryngitis d. Klebsiella pneumonia

Ans: (D) Klebsiella pneumonia is a bacterial infection of the lungs that typically manifest in people with compromised immune systems or those with accompanying morbidity, especially chronic ones. It is also common among alcoholics. Aside from the typical signs and symptoms of pneumonia such as high-grade fever, malaise, and dyspnea, the client expectorates red, sticky and jelly-like sputum.

1. A nurse assessing the client with fever notes that the client also has dry and painful non-productive cough. During the interview, the nurse notes that he has hoarseness of the voice. The nurse continues to assess the client for more signs and symptoms of which disorder? a. Pneumonia b. Asthma c. Bronchiectasis d. Laryngitis

Ans: (D) Laryngitis is inflammation of the vocal cords caused by infection, overuse or of irritating substances such as smoke. In addition to fever, the client exhibits hoarseness of the voice and has dry painful non-productive cough.

Which of the following anatomic landmark associations is correct? A) 2nd intercostal space for needle insertion in tension pneumothorax B) T6 for lower margin of endotracheal tube C) Sternal angle marks the 4th rib D) 5th intercostal space for chest tube insertion

Ans: A Chapter: 08 Page and Header: 283, Anatomy and Physiology Feedback: The 2nd intercostal space is indeed the correct location for insertion of a needle in tension pneumothorax. The other answers are incorrect. T4 marks the approximate bifurcation of the trachea and therefore marks the inferior limit for an endotracheal tube on chest X-ray. The sternal angle marks the 2nd rib, which helps establish the 2nd interspace for needle insertion as above or locations for cardiac auscultation (aortic and pulmonary areas). Finally, the 4th intercostal space is normally used for chest tube insertion.

When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology? A) Bronchitis B) Simple asthma C) Cystic fibrosis D) Heart failure

Ans: A Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: Adventitious sounds that clear with cough are usually consistent with bronchitis or atelectasis. The other conditions would not be associated with findings that cleared with a cough.

Which of the following conditions would produce a hyperresonant percussion note? A) Large pneumothorax B) Lobar pneumonia C) Pleural effusion D) Empyema

Ans: A Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: There is a great deal of free air in the chest with a large pneumothorax, which produces a hyperresonant note. The other three conditions produce dullness by dampening the percussion note with fluid.

A 62-year-old construction worker presents to your clinic, complaining of almost a year of chronic cough and occasional shortness of breath. Although he has had worsening of symptoms occasionally with a cold, his symptoms have stayed about the same. The cough has occasional mucous drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married and has two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. On examination you see a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms? A) Spontaneous pneumothorax B) Chronic obstructive pulmonary disease (COPD) C) Asthma D) Pneumonia

Ans: B Chapter: 08 Page and Header: 314, Table 8-2 Feedback: This disorder is insidious in onset and generally affects the older population with a smoking history. The diameter of the chest is often enlarged like a barrel. Percussing the chest elicits hyperresonance, and during auscultation there are often distant breath sounds. Coarse breath sounds of rhonchi are also often heard. It is important to quantify this patient's exercise capacity because it may affect his employment and also allows you to follow for progression of his disease. You must offer smoking cessation as an option.

A 55-year-old smoker complains of chest pain and gestures with a closed fist over her sternum to describe it. Which of the following diagnoses should you consider because of her gesture? A) Bronchitis B) Costochondritis C) Pericarditis D) Angina pectoris

Ans: D Chapter: 08 Page and Header: 290, The Health History Feedback: The clenched fist of Levine's sign, while not completely specific for ischemic pain, should definitely cause you to consider this etiology. Bronchitis is usually painless and pericarditis can produce a sharp pain which worsens with inspiration. This is called pleuritic pain and can be associated with pneumonia and other chest diseases. Costochondritis is a parasternal pain, usually well localized. It is exquisitely tender.

A 68-year-old retired postman presents to your clinic, complaining of dull, intermittent left-sided chest pain over the last few weeks. The pain occurs after he mows his lawn or chops wood. He says that the pain radiates to the left side of his jaw but nowhere else. He has felt light-headed and nauseated with the pain but has had no other symptoms. He states when he sits down for several minutes the pain goes away. Ibuprofen, Tylenol, and antacids have not improved his symptoms. He reports no recent weight gain, weight loss, fever, or night sweats. He has a past medical history of high blood pressure and arthritis. He quit smoking 10 years ago after smoking one pack a day for 40 years. He denies any recent alcohol use and reports no drug use. He is married and has two healthy children. His mother died of breast cancer and his father died of a stroke. His younger brother has had bypass surgery. On examination you find him healthy-appearing and breathing comfortably. His blood pressure is 140/90 and he has a pulse of 80. His head, eyes, ears, nose, and throat examinations are unremarkable. His lungs have normal breath sounds and there are no abnormalities with percussion and palpation of the chest. His heart has a normal S1 and S2 and no S3 or S4. Further workup is pending. Which disorder of the chest best describes these symptoms? A) Angina pectoris B) Pericarditis C) Dissecting aortic aneurysm D) Pleural pain

Ans: A Chapter: 08 Page and Header: 312, Table 8-1 Feedback: Angina causes dull chest pain felt in the retrosternal area or anterior chest. It often radiates to the shoulders, arms, neck, and jaw. It is associated with shortness of breath, nausea, and sweating. The pain is generally relieved by rest or medication after several minutes. This patient needs to be admitted to the hospital for further workup for his accelerating symptoms.

A 17-year-old high school senior presents to your clinic in acute respiratory distress. Between shallow breaths he states he was at home finishing his homework when he suddenly began having right-sided chest pain and severe shortness of breath. He denies any recent traumas or illnesses. His past medical history is unremarkable. He doesn't smoke but drinks several beers on the weekend. He has tried marijuana several times but denies any other illegal drugs. He is an honors student and is on the basketball team. His parents are both in good health. He denies any recent weight gain, weight loss, fever, or night sweats. On examination you see a tall, thin young man in obvious distress. He is diaphoretic and is breathing at a rate of 35 breaths per minute. On auscultation you hear no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe. What disorder of the thorax or lung best describes his symptoms? A) Spontaneous pneumothorax B) Chronic obstructive pulmonary disease (COPD) C) Asthma D) Pneumonia

Ans: A Chapter: 08 Page and Header: 314, Table 8-2 Feedback: Spontaneous pneumothorax occurs suddenly, causing severe dyspnea and chest pain on the affected side. It is more common in thin young males. On auscultation of the affected side there will be no breath sounds and on percussion there is hyperresonance or tympany. There will be an absence of fremitus to palpation. Given this young man's habitus and pneumothorax, you may consider looking for features of Marfan's syndrome. Read more about this condition.

A patient with longstanding COPD was told by another practitioner that his liver was enlarged and this needed to be assessed. Which of the following would be reasonable to do next? A) Percuss the lower border of the liver B) Measure the span of the liver C) Order a hepatitis panel D) Obtain an ultrasound of the liver

Ans: B Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: In this patient, measuring the span of the liver saved the patient an involved workup, because it was normal. His history of COPD is consistent with flattening of the diaphragms, which pushed the liver edge down while the actual size of the liver remained the same. Percussing the lower border of the liver alone caused this referral, because it was assumed that the liver was enlarged.

Which of the following percussion notes would you obtain over the gastric bubble? A) Resonance B) Tympany C) Hyperresonance D) Flatness

Ans: B Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: The gastric bubble produces one of the longest percussion notes. A patient with COPD may have hyperresonance over his chest, while a normal person would have resonance. Dullness is heard over a normal liver, and flatness is heard if one percusses a large muscle.

Which of the following occurs in respiratory distress? A) Speaking in sentences of 10-20 words B) Skin between the ribs moves inward with inspiration C) Neck muscles are relaxed D) Patient torso leans posteriorly

Ans: B Chapter: 08 Page and Header: 297, Examination of the Posterior Chest Feedback: This description is consistent with retractions that occur with respiratory distress. Other features include speaking in short sentences, use of accessory muscles, leaning forward to gain mechanical advantage for the diaphragm, and pursed lip breathing, in which the patient exhales against his lips, which are pressed together.

A 36-year-old teacher presents to your clinic, complaining of sharp, knifelike pain on the left side of her chest for the last 2 days. Breathing and lying down make the pain worse, while sitting forward helps her pain. Tylenol and ibuprofen have not helped. Her pain does not radiate to any other area. She denies any upper respiratory or gastrointestinal symptoms. Her past medical history consists of systemic lupus. She is divorced and has one child. She denies any tobacco, alcohol, or drug use. Her mother has hypothyroidism and her father has high blood pressure. On examination you find her to be distressed, leaning over and holding her left arm and hand to her left chest. Her blood pressure is 130/70, her respirations are 12, and her pulse is 90. On auscultation her lung fields have normal breath sounds with no rhonchi, wheezes, or crackles. Percussion and palpation are unremarkable. Auscultation of the heart has an S1 and S2 with no S3 or S4. A scratching noise is heard at the lower left sternal border, coincident with systole; leaning forward relieves some of her pain. She is nontender with palpation of the chest wall. What disorder of the chest best describes this disorder? A) Angina pectoris B) Pericarditis C) Dissecting aortic aneurysm D) Pleural pain

Ans: B Chapter: 08 Page and Header: 312, Table 8-1 Feedback: The pain from pericarditis is usually sharp and knifelike and is located over the left side of the chest. Change of position, breathing, and coughing often make the pain worse, whereas leaning forward improves the pain. Pericarditis is often seen in rheumatologic diseases such as systemic lupus and in patients with chronic kidney disease. Patients also experience this after a myocardial infarction. You can read more about Dressler's syndrome.

A grandmother brings her 13-year-old grandson to you for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and tells you that it has been that way for quite awhile. He states he has no symptoms from it and he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was deployed to the Middle East. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. On examination you see a teenage boy appearing his stated age. On visual examination of his chest you see that the lower portion of the sternum is depressed. Auscultation of the lungs and heart are unremarkable. What disorder of the thorax best describes your findings? A) Barrel chest B) Funnel chest (pectus excavatum) C) Pigeon chest (pectus carinatum) D) Thoracic kyphoscoliosis

Ans: B Chapter: 08 Page and Header: 317, Table 8-4 Feedback: Funnel chest is caused by a depression in the lower portion of the sternum. If severe enough there can be compression of the heart and great vessels, leading to murmurs on auscultation. This is usually only a cosmetic problem, but corrective surgeries can be performed if necessary.

A 62-year-old smoker complains of "coughing up small amounts of blood," so you consider hemoptysis. Which of the following should you also consider? A) Intestinal bleeding B) Hematoma of the nasal septum C) Epistaxis D) Bruising of the tongue

Ans: C Chapter: 08 Page and Header: 290, The Health History Feedback: When you suspect hemoptysis, you must consider other etiologies for bleeding. Commonly, epistaxis can mimic this as well as bleeding from the gastrointestinal tract. The other answers, although they involve bleeding, are contained or distant from the pharynx.

A 21-year-old college senior presents to your clinic, complaining of shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory symptoms, chest pain, gastrointestinal symptoms, or urinary tract symptoms. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray but is otherwise on no other medications. She has had no surgeries. Her mother has allergies and eczema and her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and she has recently started a job as a bartender in town. On examination she is in no acute distress and her temperature is 98.6. Her blood pressure is 120/80, her pulse is 80, and her respirations are 20. Her head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this best describe? A) Spontaneous pneumothorax B) Chronic obstructive pulmonary disease (COPD) C) Asthma D) Pneumonia

Ans: C Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: Asthma causes shortness of breath and a nocturnal cough. It is often associated with a history of allergies and can be made worse by exercise or irritants such as smoke in a bar. On auscultation there can be normal to decreased air movement. Wheezing is heard on expiration and sometimes inspiration. The duration of wheezing in expiration usually correlates with severity of illness, so it is important to document this length (e.g., wheezes heard halfway through exhalation). Realize that in severe asthma, wheezes may not be heard because of the lack of air movement. Paradoxically, these patients may have more wheezes after treatment, which actually indicates an improvement in condition. Peak flow measurements help to discern this.

Which lung sound possesses the characteristics of being louder and higher in pitch, with a short silence between inspiration and expiration and with expiration being longer than inspiration? A) Bronchovesicular B) Vesicular C) Bronchial D) Tracheal

Ans: C Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: These sounds are consistent with bronchial breath sounds. Be alert for these, as they may occur elsewhere and indicate a pneumonia or other pathology. The current explanation for this phenomenon is that the sound from the trachea is carried very well to the chest wall by fluid. This same explanation explains "ee" to "aa" changes, whispered pectoriloquy, bronchophony, and other circumstances in which high-frequency sounds, normally blocked by the air-filled alveoli, could be transmitted to the chest wall.

You are at your family reunion playing football when your uncle takes a hit to his right lateral thorax and is in pain. He asks you if you think he has a rib fracture. You are in a very remote area. What would your next step be? A) Call a medevac helicopter B) Drive him to the city (4 hours away) C) Press on his sternum and spine simultaneously D) Examine him for tenderness over the injured area

Ans: C Chapter: 08 Page and Header: 309, Special Techniques Feedback: The area involved in the injury will of course be tender. If you press in an area remote to the injury, but over the same bone which may be involved, you can produce tenderness at the site of injury. This would indicate that there may be a fracture at the lateral ribs. Fortunately, this maneuver did not reproduce pain remotely, and your uncle simply sat on the sidelines for the rest of the game.

A 75-year-old retired teacher presents to your clinic, complaining of severe, unrelenting anterior chest pain radiating to her back. She describes it as if someone is "ripping out her heart." It began less than an hour ago. She states she is feeling very nauseated and may pass out. She denies any trauma or recent illnesses. She states she has never had pain like this before. Nothing seems to make the pain better or worse. Her medical history consists of difficult-to-control hypertension and coronary artery disease requiring two stents in the past. She is a widow. She denies any alcohol, tobacco, or illegal drug use. Her mother died of a stroke and her father died of a heart attack. She has one younger brother who has had bypass surgery. On examination you see an elderly female in a great deal of distress. She is lying on the table, curled up, holding her left and right arms against her chest and is restless, trying to find a comfortable position. Her blood pressure is 180/110 in the right arm and 130/60 in the left arm, and her pulse is 120. Her right carotid pulse is bounding but the left carotid pulse is weak. She is afebrile but her respirations are 24 times a minute. On auscultation her lungs are clear and her cardiac examination is unremarkable. You call EMS and have her taken to the hospital's ER for further evaluation. What disorder of the chest best describes her symptoms? A) Angina pectoris B) Pericarditis C) Dissecting aortic aneurysm D) Pleural pain

Ans: C Chapter: 08 Page and Header: 312, Table 8-1 Feedback: A dissecting aortic aneurysm is associated with a ripping or tearing sensation that radiates to the neck, back, or abdomen. Because blood supply to the brain and extremities is disrupted, syncope and paraplegia or hemiplegia can occur. Blood pressure will usually be different between the two arms, and the carotid pulses often show an asymmetry. This is because the aneurysm decreases flow distally and causes inequality of flow between sides.

A 25-year-old accountant presents to your clinic, complaining of intermittent lower right-sided chest pain for several days. He describes it as knifelike and states it only lasts for 3 to 5 seconds, taking his breath away. He states he feels like he has to breathe shallowly to keep it from recurring. The only thing that makes it better is lying quietly on his right side. It is much worse when he takes a deep breath. He has taken some Tylenol and put a heating pad on his side but neither has helped. He remembers that 2 weeks ago he had an upper respiratory infection with a severe hacking cough. He denies any recent trauma. His past medical history is unremarkable. His parents and siblings are in good health. He has recently married, and his wife has a baby due in 2 months. He denies any smoking or illegal drug use. He drinks two to three beers once a month. He states that he eats a healthy diet and runs regularly, but not since his recent illness. He denies any cardiac, gastrointestinal, or musculoskeletal symptoms. On examination he is lying on his right side but appears quite comfortable. His temperature, blood pressure, pulse, and respirations are unremarkable. His chest has normal breath sounds on auscultation. Percussion of the chest is unremarkable. During palpation the ribs are nontender. What disorder of the chest best describes his symptoms? A) Pericarditis B) Chest wall pain C) Pleural pain D) Angina pectoralis

Ans: C Chapter: 08 Page and Header: 312, Table 8-1 Feedback: This pain is sharp and knifelike and occurs over the affected area of pleura. Breathing deeply usually makes the pain worse, whereas lying quietly on the affected side makes the pain better. Pleurisy often occurs from inflammation due to an infection, neoplasm, or autoimmune disease.

Which of the following is consistent with good percussion technique? A) Allow all of the fingers to touch the chest while performing percussion. B) Maintain a stiff wrist and hand. C) Leave the plexor finger on the pleximeter after each strike. D) Strike the pleximeter over the distal interphalangeal joint.

Ans: D Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: Percussion takes practice to master. Most struggle initially with keeping the wrist and hand relaxed. Other challenges include removing the plexor quickly and keeping the other fingers off the chest wall. These can dampen the sound you are trying to obtain. The ideal target for the plexor is the distal interphalangeal joint.

A patient complains of shortness of breath for the past few days. On examination, you note late inspiratory crackles in the lower third of the chest that were not present a week ago. What is the most likely explanation for these? A) Asthma B) COPD C) Bronchiectasis D) Heart failure

Ans: D Chapter: 08 Page and Header: 296, Techniques of Examination Feedback: The timing of crackles within inspiration provides important clues. These late inspiratory crackles that appeared suddenly would be most consistent with heart failure. COPD and asthma usually produce early inspiratory crackles. Bronchiectasis, as seen in cystic fibrosis, classically produces mid-inspiratory crackles, but this is not always reliable. Interestingly, end-expiratory crackles can be heard in asthma on occasion.

A 60-year-old baker presents to your clinic, complaining of increasing shortness of breath and nonproductive cough over the last month. She feels like she can't do as much activity as she used to do without becoming tired. She even has to sleep upright in her recliner at night to be able to breathe comfortably. She denies any chest pain, nausea, or sweating. Her past medical history is significant for high blood pressure and coronary artery disease. She had a hysterectomy in her 40s for heavy vaginal bleeding. She is married and is retiring from the local bakery soon. She denies any tobacco, alcohol, or drug use. Her mother died of a stroke and her father died from prostate cancer. She denies any recent upper respiratory illness, and she has had no other symptoms. On examination she is in no acute distress. Her blood pressure is 160/100 and her pulse is 100. She is afebrile and her respiratory rate is 16. With auscultation she has distant air sounds and she has late inspiratory crackles in both lower lobes. On cardiac examination the S1 and S2 are distant and an S3 is heard over the apex. What disorder of the chest best describes her symptoms? A) Pneumonia B) Chronic obstructive pulmonary disease (COPD) C) Pleural pain D) Left-sided heart failure

Ans: D Chapter: 08 Page and Header: 314, Table 8-2 Feedback: In left-sided heart failure, fluid starts "backing up" into the lungs because the heart is unable to handle the volume. The excess fluid collects in the dependent areas, causing crackles in the bases of the lower lobes. Sitting up allows patients to breathe easier. The two main causes are chronic high blood pressure and coronary artery disease, which lead to myocardial ischemia and decreased contractility of the heart.

A 47-year-old receptionist comes to your office, complaining of fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only gotten worse, despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. On examination you see a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated, at 101. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examinations are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement, and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms? A) Spontaneous pneumothorax B) Chronic obstructive pulmonary disease (COPD) C) Asthma D) Pneumonia

Ans: D Chapter: 08 Page and Header: 318, Table 8-5 Feedback: Pneumonia is usually associated with dyspnea, cough, and fever. On auscultation there can be coarse or fine crackles heard over the affected lobe. Percussion over the affected area is dull and there is often an increase in fremitus. Egophony and pectoriloquy are heard because of increased transmission of high-pitched components of sounds. These higher frequencies are usually filtered out by the multiple air-filled chambers of the alveoli.

when is unilateral decreased fremitus seen?

Asymmetric decreased fremitus raises the likelihood of unilateral pleural effusion, pneumothorax, or neoplasm, which decreases transmission of low- frequency sounds;

When are bronchial breath sounds heard?

Bronchial, or louder, harsher and higher in pitch, with a short silence (gap) between inspiratory and expiratory sounds. Expiratory sounds last longer than inspiratory sounds.

When percussing, where would a normal finding of a Tympanitic note be found?

Gastric air bubble or puffed-out cheek

what adventitious breath sound does this describe? Intermittent, nonmusical, and brief. Like dots in time

Crackles (or Rales)

when percussing the lungs, when does generalized hyperresonance replace resonance?

Generalized hyperresonance is common over the hyperinflated lungs of COPD or asthma.

when percussing the lungs posteriorly, when does dullness replace resonance?

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.

duration of lung sound: bronchial

Expiratory sounds last longer than inspiratory ones

Fremitus is decreased or absent when (posteriorly)?

Fremitus is decreased or absent when the voice is higher pitched or soft or when the transmission of vibrations from the larynx to the surface of the chest is impeded by a thick chest wall, an obstructed bronchus, COPD, or pleural effusion, fibrosis, air (pneumothorax), or an infiltrating tumor.

Fremitus is typically more prominent where (posteriorly)?

Fremitus is typically more prominent in the interscapular area than in the lower lung fields and easier to detect over the right lung than the left.

what is fremitus?

Fremitus refers to the palpable vibrations that are transmitted through the bronchopulmonary tree to the chest wall as the patient is speaking and is normally symmetric.

what is good technique for percussion?

Hyperextend the middle finger of your left hand, known as the pleximeter finger. Press its distal interphalangeal joint firmly on the lung surface to be percussed. Avoid surface contact by any other part of the hand because this dampens out vibrations. With a quick, sharp but relaxed wrist motion, strike the pleximeter finger with the right middle finger, called the plexor finger. Aim at your distal interphalangeal joint Withdraw your striking finger quickly to avoid damping the vibrations you have created

What is a unilateral lag and when do you see it?

Impaired respiratory movement on one or both sides or a unilateral lag (or delay) in movement. Unilateral impairment or lagging suggests pleural disease from asbestosis or silicosis; it is also seen in phrenic nerve damage or trauma

duration of lung sound: Tracheal

Inspiratory and expiratory sounds are almost equal

duration of lung sound: bronchovesicular

Inspiratory and expiratory sounds are almost equal.

duration of lung sound: vesicular

Inspiratory sounds last longer than expiratory sounds.

Describe the characteristics of this percussion note: Resonant

Intensity: Loud Pitch: low Duration: long

Describe the characteristics of this percussion note: Tympanitic

Intensity: loud Pitch: high Duration: longer

Describe the characteristics of this percussion note: Dull

Intensity: medium Pitch: medium Duration: medium

Describe the characteristics of this percussion note: Flat

Intensity: soft Pitch: high Duration: short

Describe the characteristics of this percussion note: Hyperresonant

Intensity: very loud Pitch: lower Duration: longer

where does fremitus disappear posteriorly?

It disappears below the diaphragm.

where do you hear this normal breath sound? bronchovesicular

Often in the 1st and 2nd interspaces anteriorly and between the scapulae

where do you hear this normal breath sound? vesicular

Over most of both lungs

where do you hear this normal breath sound? bronchial

Over the manubrium, (larger proximal airways)

where do you hear this normal breath sound? Tracheal

Over the trachea in the neck

what should be considered for subacute cough?

Postinfectious cough, pertussis, acid reflux, bacterial sinusitis, and asthma can cause subacute cough.

When are vesicular breath sounds heard?

They are heard throughout inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration.

When percussing, where would a normal finding of a flat note be found?

Thigh

Foul-smelling sputum is present in:

anaerobic lung abscess, thick tenacious sputum in cystic fibrosis

A clenched fist over the sternum suggests

angina pectoris

when is unilateral increased fremitus seen?

asymmetric increased fremitus occurs in unilateral pneumonia which increases transmission through consolidated tissue

Large volumes of purulent sputum are present in

bronchiectasis and lung abscess

Intercostal tenderness is seen when?

can develop over inflamed pleurae, costal cartilage tenderness in costochondritis.

Symptoms of sleep apnea?

excessive daytime sleepiness and fatigue, snoring, awakening with a choking sensation, or morning headache.

When percussing, where would a normal finding of a Resonant note be found?

healthy lung

a hand moving from the neck to the epigastrium suggests

heartburn.

Asymmetric expansion occurs when?

in large pleural effusions.

how many steps are in the ladder pattern when percussing posteriorly? anteriorly?

posterior: 7 steps, so percussing a total of 14 times anterior: 6 steps, so percussing a total of 12 times.

Chronic cough is seen in:

postnasal drip, asthma, gastroesophageal reflux, chronic bronchitis, and bronchiectasis

Lag occurs in ____________

underlying diseases of the lung or pleura.

how do you detect fremitus?

use either theball (the bony part of the palm atthe base of the fingers) or the ulnarsurface 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."

The most common cause of acute cough is _______. What should also be considered?

viral upper respiratory infections. Also consider acute bronchitis, pneumonia, left-sided heart failure, asthma, foreign body, smoking, and ace-inhibitor therapy.

When are bronchovesicular breath sounds heard?

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.

What are the characteristics of purulent sputum and when is it seen?

yellow or green—often accompanies bacterial pneumonia.