pulm basics
Pectus excavatum vs Pectus carinatum
Pectus excavatum: Funnel chest
Depression in lower part of sternum, compression of heart and great vessels may cause murmur
Pectus carinatum: Pidgeon chest
Sternum is displaced anteriorly, increasing the AP diameter, costal cartilage adjacent to the protruding sternum are depressed
Differentiate fine vs coarse crackles (sorry its not in the correct category)
hint: think characteristics, when it occurs in breathing cycle, location, physiology, can you clear with cough?, associated disorders/diseases, etc
Fine Crackles
Characteristics: Discontinuous, soft, high-pitched sounds, very brief (think Velcro being pulled apart); Occurs in mid to late inspiration; Intermittent, nonmusical, brief; does not clear with cough; Commonly heard at the lung bases; Result from a series of tiny explosions when small distal airways deflated during expiration, pop open during inspiration. Thin secretions in the airways
interstitial pulmonary fibrosis, Pneumonia, Congestive heart failure, atelectasis
Course Crackles/Rales
Characteristics: Discontinuous, loud, low-pitched explosive sounds (think slurping the end of fountain drink); Inspiration or expiration; Could clear with cough; Commonly at lung bases; Movement of fluid, thicker fluid or air through fluid in small airways
Pneumonia, bronchiectasis, interstitial lung fibrosis, congestive heart failure
what does an ABNORMAL (CONSOLIDATION OR AIR-LESS) LUNG look like on physical exam?
+/- Symmetric chest expansion
Increased Tactile Fremitus
Dull to percussion
Adventitious sounds over the involved area or bronchial or bronchovesicular over the involved area
Transmitted Voice Sounds (Spoken words louder, clearer; Spoken “ee” heard as “ay”; Whispered words louder, clearer)
Social Location
The intersection of identities (race, gender, age, class, sexuality, ability, profession, etc.) that shape how we see and experience the world
lung cancer screenings - share what you know
The U.S. Preventative Services Task Force (USPSTF) recommend:
Annual screening with low-dose computer tomography (LDCT) for current smokers (or those that have quit in the last 15 years) if they have smoked an average of one pack of cigarettes for 20 years and are aged 55 to 80.
American Cancer Society also recommends annual screening but only until age 74
Costochondritis
muscle strain from coughing
Usually produces severe chest pain and best heard in left lateral position. Can be caused by tracheobronchial injury, blunt trauma, pulmonary disease, recreational drugs, childbirth, rapid ascent from scuba diving or may be spontaneous
Mediastinal Crunch (Hamman Sign)
Characteristics: Series of precordial crackles synchronous with the heartbeat, not with respiration
Physiology: Air entry into the mediastinum -> mediastinal emphysema (pneumomediastinum).
normal breath sound heard often in 1st and 2nd interspaces anteriorly and b/n scapulae
What is bronchovesicular?
Positionality:
Our awareness of how these identities confer power and privilege (or marginalization) in different contexts
soft, relative low normal breath sound where inspiration > expiratory sounds
what is vesicular?
serous membrane lacking sensory Ns
What is visceral pleurae?
Pleuritic pain can be a sign of a PE. When does this pain occur in the breathing cycle and what causes this pain?
Pain occurs during inspiration.
Parietal pleurae (richly innervated by the intercostal and phrenic nerves). It is irritation of this that causes pleuritic pain with deep inspiration (pneumonia, PE).
differentiate tachypnea vs hyperpnea/hyperventilation
tachypnea - rapid shallow breathing; >25 breaths/min
hyperpnea - rapid, deep breathing
Cultural Humility
ongoing, lifelong process of self-reflection, self-critique, and openness to understanding other people's unique cultural experiences without assuming mastery or falling into stereotypes
witnessed apnea description
Breathing cessation for >10 seconds
the physics that keeps lung in contact with thoracic wall
what is surface tension?
Pt comes in c/o daytime sleepiness, snoring and disordered sleep. What problems will you ask them about?
Ask about problem with snoring, choking sensation, morning headache
soft intensity, high pitched, short note of percussion associated with large pleural effusion
what is flat?
name 2 of the original 10 ACEs
Physical abuse
Emotional abuse
Sexual abuse
Physical neglect
Emotional neglect
Witnessing domestic violence
Household member substance abuse
Household member mental illness
Parental separation or divorce
Incarcerated household member
The 3 categories for duration of cough and what defines them
Duration of cough – acute is less than 3 weeks, subacute is 3-8 weeks, and chronic is more than 8 weeks
Best place for chest tube insertion b/n which two ribs?
4-5th ribs
Pt is c/o SOB. What are two important types of dyspnea to consider investigating?
Orthopnea- shortness of breath when supine
Paroxysmal nocturnal dyspnea- shortness of breath at night relieved by sitting up
Decreased or Absent fremitus vs Increased fremitus
when to expect to see these findings?
Decreased or Absent fremitus – obstruction of transmission of vibration; Thickened pleurae, pleural effusion, pneumothorax, tumor, COPD, obstructed bronchus
Increased fremitus – enhances the transmission of vibration; Consolidated tissue or inflammation around a lung abscess
List out one of the following and describe what they mean:
The Three Es
The Four Rs
The Core Principles of TIC
The Three E’s: Event – Experience – Effect
The Four R’s:Realize – Recognize – Respond – Resist Re-traumatization
The Core Principles: Safety, Trust, Collaboration, Empowerment, Cultural Humility
During a routine physical examination of a healthy adult, percussion is performed over the right lower anterior chest wall overlying the liver. What percussion note and physical characteristics are typically elicited over this location?
Dull note with medium intensity, medium pitch, and medium duration
Solid organs like the liver yield a dull percussion note characterized by medium intensity, medium pitch, and medium duration.