PET Exam 3 - Thorax and Lungs

Angle of Louis (Sternal Angle)

What anatomical landmark is formed by the junction of the manubrium and the body of the sternum?

Second rib

Which rib attaches directly adjacent to the Sternal Angle (Angle of Louis)?

Tracheal bifurcation and beginning of the aortic arch

What two major internal cardiovascular and respiratory structures lie at the level of the Angle of Louis?

Start at the 12th rib and count upward

How do you count ribs posteriorly during a physical examination?

Below the 2nd rib

Where is the 2nd intercostal space located relative to the 2nd rib?

2nd intercostal space

What is the recommended anatomical location for needle decompression of a tension pneumothorax?

4th intercostal space

What intercostal space is usually selected for chest tube insertion?

4th rib

What rib level marks the lower border of a properly placed endotracheal tube?

Along the inferior margin (lower edge) of each rib

Where do neurovascular structures run in relation to each rib?

Just superior to the rib (along the top edge)

Where should needles and tubes be placed relative to a rib to avoid neurovascular injury?

C7 spinous process

What is usually the most prominent bony landmark palpable at the base of the neck when the patient flexes their neck?

7th rib

What rib level corresponds to the inferior tip of the scapula?

Area bounded by pectoralis major, latissimus dorsi, and nipple line in the mid-axillary line

What is the triangle of safety used for chest tube placement?

2 to 4 cm above the medial clavicles

How far above the clavicles do the lung apices extend anteriorly?

Right mainstem bronchus

Which mainstem bronchus is wider, shorter, and more vertical, making it more prone to aspiration pneumonia?

Parietal pleura

Which pleural layer lines the inner thoracic cavity and is heavily innervated with pain fibers?

To reduce friction and maintain surface tension that keeps the lungs expanded

What is the physiological function of the fluid in the potential pleural space?

Diaphragm contracts/descends and external intercostals expand the thorax

What muscle movements drive normal inspiration and lower intrathoracic pressure?

Passive elastic recoil of the lungs and chest wall

What mechanism produces normal resting expiration?

Boyle's Law

Which gas law states that increasing thoracic volume decreases intrathoracic pressure, driving air into the lungs?

Airflow obstruction (such as in asthma or COPD)

What clinical condition is suggested by a prolonged expiratory phase during breathing?

Diaphragmatic weakness or muscle fatigue

What does paradoxical abdominal movement during inspiration signal?

PE, pneumothorax, pneumonia, or acute myocardial ischemia

What are the high-yield differential diagnoses for sudden pleuritic chest pain?

Inspection, Palpation, Percussion, Auscultation (IPPA)

What is the correct standard sequence for performing the physical examination of the thorax and lungs?

AP diameter is less than the transverse diameter

What is the normal ratio of anteroposterior (AP) diameter to transverse diameter of the chest in a healthy adult?

Increased AP diameter equal to or exceeding transverse diameter due to COPD hyperinflation

What is a barrel chest and what chronic respiratory condition causes it?

Pleural effusion, pneumothorax, or atelectasis on the affected side

What causes a unilateral decrease in chest expansion during palpation?

Tactile fremitus

What physical exam technique evaluates palpable vocal vibrations transmitted through the bronchopulmonary system to the chest wall?

Lung consolidation (e.g., lobar pneumonia)

What pathological state causes increased tactile fremitus?

Pleural effusion, pneumothorax, or bronchial obstruction

What pathological states cause decreased or absent tactile fremitus?

Shifts away from the affected side

In which direction does the trachea shift in a tension pneumothorax or large pleural effusion?

Shifts toward the affected side

In which direction does the trachea shift in significant lobar atelectasis or lung collapse?

Accessory muscle use, intercostal retractions, cyanosis, and tripoding

What inspection findings indicate increased work of breathing and respiratory distress?

Dominant hand middle finger acts as plexor, non-dominant hand middle finger acts as pleximeter

How are the fingers positioned and used during chest percussion?

Ladder pattern

What side-to-side pattern should be followed across paired sites when percussing and auscultating the chest?

Flatness

What percussion note is very soft, high-pitched, short, and heard over bone, thigh, or a large pleural effusion?

Dullness

What percussion note is soft and high-pitched, characteristic of the liver or consolidated lung tissue in pneumonia?

Resonance

What percussion note is loud, low-pitched, and representative of normal air-filled adult lung tissue?

Hyperresonance

What percussion note is very loud, lower-pitched, and indicates lung hyperinflation in COPD or pneumothorax?

Tympanitic

What percussion note is loud, musical, and drum-like, heard over the gastric air bubble or a large pneumothorax?

5 to 6 cm

What is the normal distance of diaphragmatic excursion in a healthy adult?

Percuss the diaphragm level at full expiration, mark it, then percuss at full inspiration, and measure the distance between marks

How is diaphragmatic excursion measured clinically?

Directly on bare skin with the stethoscope diaphragm

How must chest auscultation be performed for accurate assessment?

Vesicular breath sounds

Which breath sounds are soft, low-pitched, heard over most peripheral lungs, with inspiration lasting longer than expiration?

Bronchovesicular breath sounds

Which breath sounds have equal inspiratory and expiratory durations and are normally heard in the 1st and 2nd interspaces anteriorly?

Bronchial breath sounds

Which breath sounds are loud and high-pitched, heard over the manubrium, with expiration longer than or equal to inspiration?

Tracheal breath sounds

Which breath sounds are very loud and high-pitched, heard specifically over the trachea in the neck?

Lung consolidation (such as lobar pneumonia)

What does finding bronchial breath sounds in the peripheral lung fields indicate?

Crackles (Rales)

What discontinuous, popping adventitious breath sounds result from fluid accumulation or opening of collapsed small airways?

Wheezes

What continuous, high-pitched musical adventitious breath sounds indicate narrowed airways in asthma or COPD?

Rhonchi

What low-pitched, snoring adventitious breath sounds are caused by secretions in large airways and often clear with coughing?

Pleural friction rub

What grating, superficial adventitious sound occurring in both inspiration and expiration is caused by inflamed pleural surfaces rubbing together?

Stridor

What harsh, high-pitched, predominantly inspiratory sound signals upper airway obstruction and requires immediate medical escalation?

12 to 20 breaths per minute

What is the normal resting respiratory rate for a healthy adult?

Tachypnea (>20 breaths/min)

What term describes rapid breathing, often caused by fever, pain, anxiety, hypoxemia, or acidosis?

Bradypnea (<12 breaths/min)

What term describes abnormally slow breathing, commonly caused by opioid overdose or central nervous system injury?

Cheyne-Stokes respirations

What breathing pattern features repeating cycles of gradually deepening and faster breathing followed by gradual decrease and temporary apnea?

Congestive heart failure, chronic kidney disease, increased intracranial pressure, or drug toxicity

What clinical conditions are associated with Cheyne-Stokes respirations?

Kussmaul breathing

What deep, rapid, labored breathing pattern occurs in response to severe metabolic acidosis such as diabetic ketoacidosis (DKA)?

Pectus excavatum

What congenital thoracic deformity presents as a distinctly depressed or sunken sternum?

Pectus carinatum

What thoracic deformity is characterized by an anterior protrusion of the sternum and costal cartilages?

Flail chest

What life-threatening condition manifests as paradoxical chest wall motion due to multiple adjacent rib fractures?

Kyphosis and Scoliosis

What spinal deformities alter chest wall mechanics and produce restrictive pulmonary impairment?

Dense solid/liquid tissue conducts sound and vibration far better than air-filled tissue

Why do vocal vibrations and breath sounds conduct more intensely through consolidated lung tissue than air-filled lung?

Bronchophony

What vocal resonance test is positive when the patient speaks "ninety-nine" and the words sound unusually loud and clear through the stethoscope?

Egophony

What test is positive when the patient says "EE" and it sounds like a nasal "AY" over an area of consolidation or upper edge of effusion?

Whispered pectoriloquy

What test is positive when the patient whispers "one-two-three" and the whispered words are heard clearly and distinctly through the stethoscope?

Dull percussion, bronchial breath sounds, increased tactile fremitus, positive egophony, and late inspiratory crackles

What are the classic physical exam findings in lobar pneumonia consolidation?

Dullness to flatness on percussion, diminished/absent breath sounds, and decreased tactile fremitus over the fluid

What are the classic physical exam findings directly over a pleural effusion?

Hyperresonant or tympanitic percussion, diminished/absent breath sounds, and decreased tactile fremitus on the affected side

What are the classic physical exam findings in a pneumothorax?

Hyperresonant percussion, diminished breath sounds, prolonged expiration, decreased tactile fremitus, and barrel chest

What are the classic physical exam findings in advanced COPD / emphysema?

Resonant percussion, prolonged expiration, diffuse expiratory wheezes, and decreased breath sounds during severe attacks

What are the typical physical exam findings during an acute asthma exacerbation?

Resonant percussion note, vesicular breath sounds, no adventitious sounds, and symmetric tactile fremitus

What are the expected physical examination findings in a healthy normal lung?

Resonant percussion, fine bibasilar crackles, and possible dullness at bases if secondary effusions develop

What physical exam findings are characteristic of left-sided heart failure?

Resonant percussion, rhonchi, wheezes, coarse crackles, and normal tactile fremitus

What physical exam findings are typical for chronic bronchitis?

Stethoscope, watch or timer with a second hand, tape measure, gloves, drape, and pulse oximeter

What essential equipment is needed to perform a complete thorax and lung examination?

Instruct the patient to breathe in and out through an open mouth slightly deeper than normal

What instructions should be given to the patient regarding breathing during lung auscultation?

Severe respiratory distress, cyanosis, stridor, silent chest, tracheal deviation, and unstable vital signs

What physical exam red flag findings require immediate emergency medical escalation?

T10 spinous process

At what spinous process level is the lower border of the lungs located posteriorly during quiet respiration?

The intercostal space shares its number with the rib immediately above it

How are intercostal spaces numbered?

Immediately superior to the upper border of the rib below

Where should a needle or tube enter an intercostal space to avoid the neurovascular bundle?

Second intercostal space at the midclavicular line is a classic landmark

Which intercostal space landmark is classically associated with needle decompression of pneumothorax?

Fourth to fifth intercostal space near the anterior or midaxillary line

What surface landmark is commonly used for chest-tube insertion?

Seventh to ninth intercostal space in the posterior axillary line with ultrasound guidance

What region is commonly used for thoracentesis?

Right upper, middle, and lower lobes

Which lobes make up the right lung?

Left upper and lower lobes

Which lobes make up the left lung?

Trachea → main bronchi → lobar bronchi → segmental bronchi → bronchioles → alveoli

Trace airflow from the trachea to the gas-exchange units.

Alveoli

Where does pulmonary gas exchange occur?

The right main bronchus is wider, shorter, and more vertical

Why does aspiration preferentially enter the right lung?

Right middle and lower lobes

Which lobes are most commonly affected by aspiration pneumonia?

Heart failure, cirrhosis, and nephrotic syndrome

What are classic causes of a transudative pleural effusion?

Pneumonia, malignancy, pulmonary embolism, tuberculosis, and pancreatitis

What are classic causes of an exudative pleural effusion?

Assess how dyspnea limits ordinary daily activity and exertion

How should you gauge the functional severity of dyspnea?

Episodic dyspnea with hyperventilation and perioral or extremity paresthesias

What symptom cluster suggests anxiety-related hyperventilation?

Partial lower-airway obstruction from bronchospasm, inflammation or edema, secretions, or a foreign body

What does wheezing usually indicate?

Acute: <3 weeks. Subacute: 3–8 weeks. Chronic: >8 weeks

How is cough classified by duration?

Viral upper respiratory infection

What is the most common cause of acute cough?

Viral infection or cystic fibrosis

What conditions are suggested by mucoid sputum?

Bacterial infection

What does purulent sputum suggest?

Anaerobic lung abscess or cystic fibrosis

What does foul-smelling sputum suggest?