Thorax and Lungs Section (General diagnosis)

What is barrel chest?

AP lateral diameter (1:1); seen with COPD and cystic fibrosis

What is pectus excavatum aka funnel chest?

Marked depression noted in the sternum (sunken in)

What is pectus carinatum aka pigeon chest?

Forward protrusion of the sternum (like keel of a ship)

What is tachypnea?

Rapid, shallow breathing

What is bradypnea?

Slow breathing

What is Biot’s breathing?

Characterized by groups of quick, shallow inspirations followed by irregular periods of apnea (no pattern)

What is Cheyne Stokes respiration?

Breathing pattern characterized by alternating periods of apnea and hyperpnea (has pattern); respiratory acidosis

What is Kussmaul’s breathing?

Breathing is first rapid and shallow but as metabolic acidosis worsens, breathing gradually becomes deep, slow, labored and gasping, “air hunger breathing”

How do you palpate for respiratory excursion?

Place hands over the posterior ribs and have the patient take deep breaths

How do you palpate for tactile fremitus?

Palpable vibration; have the patient say “99”

When you palpate tactile fremitus, what conditions would you hear increased fluid with?

Pneumonia

When you palpate tactile fremitus, what conditions would you hear decreased air with?

Emphysema, pneumothorax

When would a sound barrier be created during tactile fremitus?

Atelectasis and pleurisy

What is the definition of resonate?

Normal over lung tissue

What is the definition of hyperresonant?

Increased air in the chest (emphysema, pneumothorax)

What is the definition of dull?

Increased density (pneumonia, atelectasis)

How do you perform diaphragmatic excursion?

Dr asks the patient to exhale and hold it, percusses down the back in the intercostal margins, starting below the scapula, until sound change from resonant to dull; Dr marks this spot; Then the patient takes a deep breath in and holds it as the Dr. percusses down agin, marking between the two spots

What is a positive diaphragmatic excursion?

If less than 3-5 cm the patient may have pneumonia or a pneumothorax in which a chest xray is diagnostic for either

What are tracheal breath sounds?

Inspiration equal to expiration

What are bronchial breath sounds?

Expiration longer than inspiration

What are bronchovesicular breath sounds?

Inspiration equal to expiration

What are vesicular breath sounds?

Inspiration longer than expiration

Where are tracheal breath sounds?

Over the trachea

Where are bronchial breath sounds?

Over manubrium

Where are bronchovesicular breath sounds?

Between the 1st-2nd ribs anteriorly between scapulae posteriorly

Where are vesicular breath sounds?

The remaining lung field

What are rales?

Small clicking, bubbling, or rattling sounds in the lung; they are believed to occur when air opens closed air spaces; can be furthered described as moist, dry, fine, and coarse (bronchitis)

What are rhonchi?

Sounds that resemble snoring; they occur when air is blocked or becomes rough through the large airways (bronchiectasis)

What are wheezes?

High-pitched sounds produced by narrowed airways; they can be heard upon exhalation; asthma in young people and emphysema in older people

What is stridor?

Wheeze-like sound are heard proceed with vocal resonance

What is bronchophony?

If clear, distinct sounds are heard as the patient says “99”, consolidation is present

What is egophony?

If you hear “aaaaa” as the patient says “eeee”, consolidation is present

What is whispered pectoriloquy?

If the words “1,2',3” are heard clearly and distinctly, consolidation is present

What is the percussion, fremitus, and breath sounds for asthma?

• Percussion: Resonant

• Fremitus: Decreased

• Breath sound: Wheezing

What is the percussion, fremitus, and breath sounds for atelectasis?

• Percussion: Dull/flat

• Fremitus: Decreased

• Breath sound: Absent

What is the percussion, fremitus, and breath sounds for bronchiectasis?

• Percussion: Resonant

• Fremitus: Normal

• Breath sound: Rhonchi

What is the percussion, fremitus, and breath sounds for bronchitis?

• Percussion: Resonant

• Fremitus: Normal

• Breath sound: Rales

What is the percussion, fremitus, and breath sounds for emphysema?

• Percussion: Hyperresonant

• Fremitus: Decreased

• Breath sound: Wheezing

What is the percussion, fremitus, and breath sounds for pleurisy?

• Percussion: Dull

• Fremitus: Decreased

• Breath sound: Crackles (friction rub)

What is the percussion, fremitus, and breath sounds for pneumothorax?

• Percussion: Hyperresonant

• Fremitus: Decreased

• Breath sound: Decreased

What is the percussion, fremitus, and breath sounds for pneumonia?

• Percussion: Dull

• Fremitus: Increased

• Breath sound: Egophony, bronchophony, whispered pectoriloquy, crackles

What is lobar pneumonia?

Consolidation of the lung; patient presents with productive (rusty brown sputum) cough for around 10 days and fever; percussion is dull; rales increased tactile fremitus; silhouette sign and air bronchogram

What is Friedlander’s pneumonia?

Productive/currant red jelly sputum and caused by Klebsiella pneumonia; seen with old age or immune-compromised hosts

What is pneumocystis carinii?

Caused by yeast/fungus; most commonly seen in AIDS patients

What is cytomegalovirus?

Caused by CMV; most commonly seen in AIDS patients

What is tuberculosis?

Caused by mycobacterium tuberculosis; patient presents with low-grade fever, night sweats, productive cough (yellow/green sputum); small white lesions called Ghon lesions seen on xray; positive tine test/mantoux test, purified protein derivative; most definitive test for diagnosis is a sputum culture

What is pleurisy?

Inflammation of the pleura, usually producing an exudative pleural effusion; patient presents with stabbing chest pain worsened by respiration; dry/non-productive cough; decreased respiratory excursion; decreased tactile fremitus; dull on percussion; friction rub is present; positive schepelmann’s test

What is pneumothorax?

A ruptured lung causing air to become trapped in the pleural space; decreased chest expansion; decreased tactile fremitus; hyperresonant on percussion; decreased breath sounds; can occur in young, previously healthy individuals (spontaneous)

What is atelectasis?

Collapse of the lung that is usually the result of bronchial obstruction due to a mucous plug; presents with decreased tactile fremitus; dull on percussion; decreased chest expansion; decreased or absent breath sounds

What is bronchiectasis?

Irreversible focal bronchial dilation that presents with a chronic, productive cough

What is chronic broncitis/COPD?

Defined by a long-term cough with mucus; shortness of breath and wheezing; cigarette smoking is the main cause; long exposure to other things such as such a chemical fumes, dust and other substances may cause this

What is asthma?

Bronchospasm constricting airways; type 1 hypersensitivity reaction that is usually triggered by airborne allergens; patient presents with tachycardia, tachypnea, decreased tactile fremitus, and wheezing; eosinophils and IgE rise; labs: Curshmann’s spirals and Charcot Laden Crystals

What is emphysema?

Destruction of elastic pulmonary connective tissue results in permanent dilation of the alveoli air sacs; caused by a deficiency of alpha 1 anti trypsin; patient presents with decreased tactile fremitus, hyperresonant on percussion, decreased breath sounds, and wheezing

What is bronchogenic carcinoma?

Primary malignant lung tumor that starts in the area of the bronchus; long-term history of smoking (20-30 years); patient presents with coughing (non-productive) more than 30 days, afebrile, dyspnea, and weight loss

What is costochondritis?

Inflammation of the cartilage connection between the ribs and sternum; it develops as a consequence of physical activity and is worse with exercise; the pain increases while taking a deep breath; there will be palpable tenderness at the 3rd, 4th, or 5th costosternal articulation; similar to Tietze syndrome which affects only one articulation and radiates pain; can be chronic

What is herpes zoster?

Shingles; painful rash following the course of a dermatome (usually a single nerve); primarily involves the dorsal root ganglion but when it does involve cranial nerve it is most commonly seen at CN 5

What is sarcoidosis?

Is a disease in which abnormal collections of inflammatory cells (granulomas) form as nodules; most often appear in the lungs or lymph nodes; most commonly seen in African descent in the US

What is Hodgkin’s?

Cancer of the lymphatic system that can spread to the spleen; most commonly seen in young caucasian males; presents with fever, night sweats, weight loss, intense pruritis (release of IgE) and enlarged spleen; best diagnosed from biopsy

What is cystic fibrosis?

COPD (barrel chest); chronic, progressive, and frequently fatal genetic disease of the body’s mucus glands; the glands produce or secrete sweat and/or mucus; thick accumulations of mucus in the intestines and lungs; loss of excessive amounts of salt (sweat test); pancreatic insufficiency; meconium ileus