CPC Block 2 Chapter 15: Thorax PDF

Chapter 15: Thorax ================== Anatomic descriptors of the chest --------------------------------- - [Supraclavicular] = above the clavicles - [Infraclavicular] = below the clavicles - [Interscapular] = between the scapulae - [Infrascapular] = below the scapulae - [Apices of t...

Chapter 15: Thorax ================== Anatomic descriptors of the chest --------------------------------- - [Supraclavicular] = above the clavicles - [Infraclavicular] = below the clavicles - [Interscapular] = between the scapulae - [Infrascapular] = below the scapulae - [Apices of the lungs] = the uppermost portions - [Bases of the lungs] = the lowermost portions - [Upper, middle, and lower lung fields] Health history -------------- - [Dyspnea] = abnormal or labored breathing (increased work of breathing) - [Wheezing] = noise made when expiring air - [Cough]: sputum = what you cough up (e.g., blood-soaked sputum) - [Hemoptysis] = coughing up of frank blood (-ptysis = cough) - Chest pain: can lead you to **disorders of heart** - Daytime sleepiness, snoring, disordered sleep: can lead you to **disorders of ventilation** Sources of chest pain --------------------- ---------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- [Source] [Possible Causes] **Myocardium** Angina pectoris, myocardial infarction, myocarditis **Pericardium** Pericarditis **Aorta** Aortic dissection **Trachea and large bronchi** Bronchitis **Parietal pleura** Pericarditis, pneumonia, pneumothorax, pleural effusion, pulmonary embolus, connective tissue disease **Chest wall, including the skin, musculoskeletal and neurologic systems** Costochondritis, herpes zoster **Esophagus** Gastroesophageal reflux disease, esophageal spasm, esophageal tear **Extrathoracic structures such as the neck, gallbladder, and stomach** Cervical arthritis, biliary colic, gastritis ---------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- Key Examination Components -------------------------- - Survey respiration - Examine anterior & posterior chest - **IPPA** Visual examination - Inspection ------------------------------- - Rate, rhythm, depth, and effort - How many words can the patient say without taking a breath? - Cyanosis or pallor - Stridor (**squeaky noise on inspiration)** or tactile fremitus (palpatory) - Accessory muscle use - AP ratio, barrel chest Patterns of Respiration ----------------------- - Normal sinusoidal = inspirations & expirations are mostly equal and equally spaced - [Cheyne-Stokes] = rapid, deep breaths followed by interspersed periods of apnea - [Kussmaul] = usually seen in diabetic ketoacidosis; rapid, deep breath due to very low blood pH - [Bradypnea] = slow breathing - [Tachypnea] = fast breathing - [Sighing] = interspersed deep breaths - [Apnea] = cessation of breathing - [Ataxic/biot] = periods of apnea interspersed with very irregular breathing Deformities of the chest ------------------------ - Barrel chest - Pectus Carinatum (Pigeon chest) - Pectus Excavatum (Funnel chest) - Thoracic Kyphoscoliosis - Flail Chest - Indicative of multiple rib fractures Inspection - **Labored Breathing** ---------------------------------- - Cyanosis - Abdominal retractions (abdomen pokes out in inspiration due to accessory muscle use) - Tachypnea (respiratory rate) - Tripoding (using hands/arms to lift your shoulders to create negative pressure in chest) - Abnormal position of comfort - could be a sign of respiratory distress - Accessory muscle use - Intercostal muscle use - Dyspnea - Vocal quality (raspy or hoarse voice) - Flail chest Palpation - Anterior, Lateral, & Posterior ------------------------------------------ - Assessing chest expansion (symmetrical expansion with each breath) - **Tactile fremitus** - patient says "ninety-nine" while you palpate the thorax and feel the vibrations - Is it decreased, increased or absent?  - Tenderness (such as costochondritis) - Rib fracture? (step-offs = discontinuity or break; crepitus = rib moving on itself) Percussion  - The pleximeter finger is placed firmly on the chest wall (best to use 1 finger) - Striking the pleximeter finger with the right middle finger - Withdraw the striking finger quickly  - **Diaphragmatic excursion -** check for differences in diaphragmatic dullness in inspiration and expiration (usually 3-5 cm) - Diaphragmatic excursion drops on inspiration (normal) - Absent descent of the diaphragm can indicate **pleural effusion** - Percuss for liver dullness & gastric tympany Auscultation ------------ - Do not auscultate through clothes/gown - Use diaphragm for high frequencies, and bell for low frequencies - Auscultate the anterior, lateral, & posterior thorax - [Breath sounds\ ] ------------------- ---------------------------------- -------------- ----------------- Location Intensity Pitch Tracheal At the trachea Very loud Relatively high Bronchial At the bronchi Loud Relatively high Broncho-vesicular Where the bronchi meet the lungs Intermediate Intermediate Vesicular At the lungs Soft Relatively low ------------------- ---------------------------------- -------------- -----------------  - [Adventitious sounds] ---------------------------------- -------------------------------- **Crackles (aka Rales)** **Wheezes & Rhonchi** Discontinuous Continuous Intermittent, non-musical, brief Sinusoidal, musical, prolonged Like dots in time Like dashes in time Fine or coarse Wheezes = high pitched Rhonchi = low pitched Fluid in the alveoli Fluid in the larger airways ---------------------------------- -------------------------------- - Transmitted voice sounds - [Egophony] = tell patient to say "eee"... sounds like "aaa" over a consolidation of the lung - No egophony = no E to A change = no consolidation - **Consolidation** = something that replaces air-filled tissue in the lung, something that makes it solid underneath instead of air filled (e.g., pneumonia, bleeding, **[atelectasis]**, tumor, etc.) - [Bronchophony] = say "ninety-nine"... is louder over a consolidation - [Whispered pectoriloquy] = whispered words are louder over a consolidation - If you hear the whispered word thru the stethoscope → consolidation TERMS & PROCESSES TO KNOW ------------------------- - Cough - Hemoptysis - Coughing up blood - Cyanosis - Sign of **[hypoxia]** - Crackles/rales - Discontinuous nonmusical sounds - Abnormality of lung parenchyma: - E.g., pneumonia, interstitial lung disease, pulmonary fibrosis, atelectasis, heart failure - Abnormality of the airways - E.g., bronchitis, bronchiectasis - Ronchi - Low pitched sound heard on **[expiration]** - Wheezing - Continuous, high pitched sound heard on **[expiration]** - Arise from narrowed airways in asthma, COPD, and bronchitis - Stridor - High pitched sound heard on **[inspiration]** - Barrel chest - Increased AP diameter - Often accompanies aging and COPD - **Empyema** - Collection of pus in the pleural space (from google) - Asthma - Reversible bronchial hyperresponsiveness involving release of inflammatory mediators, increased airway secretions, and bronchoconstriction - Symptoms: wheezing, cough, tightness in chest - COPD - Overdistension of air spaces distal to terminal bronchioles, with destruction of alveolar septa, alveolar enlargement, and limitation of expiratory air flow - Symptoms: cough with scant mucoid sputum - Pneumothorax - Air leaks into the pleural space, usually unilaterally, and the lung recoils away from the chest wall - Forced expiratory time - Test that assesses the expiratory phase of breathing, which is typically slowed in COPD - Lung cancer - Cough, dry to productive; sputum may be blood-streaked or bloody - Tuberculosis - Cough, dry or with mucoid or purulent sputum; may be blood-streaked or bloody - Acute pulmonary embolism - Sudden occlusion of part of pulmonary arterial tree by a blood clot that originates in deep veins of legs or pelvis - Signs: sudden onset of tachypnea, dyspnea Chapter 16 & 17: Cardiovascular & Peripheral Vasc. THIS PPT WAS MOSTLY PICTURES/CHARTS -- GO THRU THE PPT S1 - closure of mitral & tricuspid valves S2 - closure of aortic & pulmonic valves JVP reflects right atrial pressure → equals central venous pressure & right ventricular end-systolic pressure  - Best estimated from the right internal jugular vein → has mot direct channel into right atrium JVP vs. JVD  - Look at neck and see external jugular popping out → then look for internal jugular → then want to lay them 30-45 deg to see if jugular is still popping out halfway up the neck → **[JVD]** - JVP can be measured by laying them back 30-45 deg and find height of meniscus to the 2nd rib - Add 5 cm if you want measurement all the way down to the atrium Carotid pulsations = single bump during systole Jugular venous pulsations = more than 1 bump Terms & Disease processes to know - Palpitations - Unpleasant awareness of the heartbeat - The most serious dysrhythmias, such as v. tach, often do not produce palpitations - Shortness of breath = dyspnea - Occurs in PE, spontaneous pneumothorax, and anxiety - Orthopnea = dyspnea when patient is supine and improves when patient sits up - Paroxysmal nocturnal dyspnea (PND) = nighttime episodes of dyspnea that awakens the patient 1 to 2 hours after falling asleep - Both occur in left ventricular heart failure, mitral stenosis, & obstructive lung disease - Edema = excessive fluid in the extravascular interstitial space - Causes: cardiac (right/left ventricular dysfunction; pulmonary hypertension) or pulmonary (obstructive lung disease) or nutritional (hypoalbuminemia), or positional - Dependent edema = appears in lowest body parts - Anasarca = severe generalized edema extending to the sacrum and abdomen - Syncope = fainting/blacking out; transient LOC followed by recovery - Usually caused by vasovagal syncope - More concerning cause: heart not providing adequate blood flow to the brain (as occurs in end-stage HF and arrhythmias) - Chest pain: - Cardiac = angina pectoris, myocardial ischemia, pericarditis - Retrosternal  - Pulmonary = pleuritic pain - Inflammation of parietal pleura - Chest wall = costochondritis - Trauma, inflammation of costal cartilage - Aortic dissection = splitting within the layers of the aortic wall - Anterior chest radiating to the neck, back, or abdomen - Esophageal (reflux) = GERD - Irritation or inflammation of the esophageal mucosa; retrosternal - Carotid artery stenosis = narrowed carotid arteries - Auscultate with bell for bruits or thrills - Causes \~10% of ischemic strokes and doubles risk of coronary heart disease - S3 and S4 sounds (what do they mean) - Pathologic; correlated with systolic (S3) & diastolic heart failure (S4) - S3 = corresponds to an abrupt deceleration of inflow across the mitral valve - S4 = corresponds to increased left ventricular end diastolic stiffness which decreases compliance; marks atrial contraction - Congestive heart failure = heart can't pump blood well enough to meet body's needs (from google) - Hypertension = high BP - Peripheral artery disease = atherosclerotic disease distal to the aortic bifurcation - Marker for cardiovascular morbidity & mortality and increases risk of death from MI - Venous thromboembolism (VTE) = DVT from PE - Pulmonary embolism = clot in lungs - Pitting edema = edema that is compressible or lessens when external pressure is applied - Ankle/brachial index (ABI) = diagnostic technique for findings suspicious of peripheral vascular disease - Measures ratio of blood pressure measurements in foot and arm Traditional Transducer Orientation 1. Transverse = probe marker to the right 2. Longitudinal = probe marker to head A drawing of a human body Description automatically generated Echogenicity Hyperechoic = white = bone, ligament, dura, nerves Anechoic = black = **[fluid]** Isoechoic = shades of gray = muscle striations Traditional vs. Butterfly Ultrasound Traditional Transducer - Piezoelectric crystals = more fragile - 3 different probe types (must physically switch out probe based on what you\'re viewing)A diagram of a ultrasound Description automatically generated with medium confidence [1. Higher resolution & less depth] OR [2. Higher depth & less resolution] Butterfly Transducer - Microchip tech = more durable - 3-in-1 probes Ultrasound Modes 2D or B-Mode - **[Most utilized setting,] brightness mode,** different shades of gray looking at two-dimensional image M-Mode - **Motion mode** (e.g., echocardiograms) - Captures ultrasound image in only one line of the 2D-mode image displayed over time - Movement of the structures positioned under that line are visualized A close-up of an ultrasound Description automatically generated Color Doppler - Color-flow ultrasound - Used to show blood flow or tissue motion in a selected 2D area;  - Red depicts movement **towards the transducer** - Blue depicts movement **away from the transducer** Pulsed Doppler - Transducer sends pulses of ultrasounds to a predetermined depth - **Venous flow** demonstrates a more continuous, band-like shape - **Arterial flow** shows a more triangular shape Power Doppler - Transducer only looks at the amplitudes of the returning frequency shifts - This setting is used for the direction of movement in **very low flow states** to better assess presence of blood flow Ultrasound Functions (Gain & Depth) - **[Gain]** → changes overall strength of returning echoes, making the image brighter or darker - **[Depth]** → increases or decreases the depth of the ultrasound Improving Image Acquisition - Probe pressure = increase probe pressure to assess deeper structures - Fanning/rocking - Sliding  - Respiratory assistance Ultrasound Artifact Shadowing - Caused by absorption of the ultrasound wave by a solid structure such as a gallstone, kidney stone, or bone Edge Shadowing - Thin acoustic shadow behind lateral edges of cystic structures - Caused by ultrasound waves encountering a curved surface at a tangential angle - Results in waves being refracted with very few returning to the probe Posterior Enhancement - Structures behind an echo-free substance, such as fluid, appear brighter - This is the reason for wanting a fluid bladder when performing transabdominal pelvic ultrasound Reverberation - Occurs when sound encounters two highly reflective layers (such as the lung pleura) - The sound is bounced back and forth between the two layers before returning to the transducer - These are also called "A lines"  Comet Tail - Produced by the front and back of a very strong reflector (such as an air bubble) Ring Down - Produced by **fluid collection** surrounded by any air bubbles - More commonly called B lines