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chapter 18 - thorax and lungs - assement of common respiratory conditions

Normal Lung (for comparison)

Inspection: AP<transverse diameter, relaxed posture, normal musculature; rate 10-18/min, regular, no cyanosis, or pallor; palpation: symmetric expansion; tactile fremitus present and equal bilaterally, diminishing toward periphery; no lumps, masses or tenderness; Percussion: resonant. diaphragmatic excursion 3-5cm and equal bilaterally; Auscultation: vesicular over peripheral fields; bronchovesicular parasternally (anterior) and between scapulae (posterior); infant and young child - bronchovesicular throughout; Adventitious Sounds: none

Atelectasis (Collapse) - Condition

collapesed shrunken section of alveoli or an entire lung as reslt of 1)airway obstruction, alveolar body beyond it is gradually absorbed by pulmonary capillaries, and alvolar walls cave in; 2) compression on lung, 3) lack of surfactant

Atelectasis (Collapse) - Observations

Inspection: cough. lag on expansion on affected side, increased respiratory rate and pulse, possible cyanosis; Palpation: chest expansion decreased on affected side, tactile fremitus decreased or absent over area; w/large collapse, tracheal shift toward affected side; Percussion: dull over area; Auscultation: breath sounds decreased vesicular or absent over area; voice sounds variable, usually decreased or absent over affected area; Adventitious Sounds: none if bronchus is obstructed; occasional fine crackles if bronchus is patent

Lobar Pneumonia - Condition

infection in lung parenchyma leaves alveolar membrane edematous and porous, so RBC and WBCs pass from blood to alveoli; alveoi progressively fill up (become consolidated) w/bacteria, solid cellualr debris, fluid, and blood cells, whcih replace alveolar air; this decreases surface area of respiratory membrane, causing hypoxemia

Lobar Pneumonia - Observations

Inspection: increased respiratory rate; gaurding and lag on expansion on affected side; children - sternal retraction, nasal flaring; Palpation: chest expansion decreased on affected side; tactile fremitus increased if bronchus patent, decresed if bronchus obstructed; Percussion: dull over lobar pneumonia; Auscultation: breath sounds louder w/patent bronchus, as if coming directly from larynx; voice sounds have increased clarity; bronchophyony, egophony, whispered pectoriloquy present; children - diminished breath sounds may occur early in pneumonia; Adevntitious sounds: cracles, fine to medium

Bronchitis - Condition

proliferation of mucus glands in the passageways, resulting in excessive mucus secretion; inflammation of bronchi with partial obstruction of bronchi by secretions or constriction; sections of lung distal to obstruction may be deflated; bronchitis may be acute or chronic with recurrent productive cough; chronic bronchitis is usually caused by cigarette smoking

Bronchitis - Observations

Inspection: hacking, rasping cough preductive of thick mucoid sputum; chronic - dyspnea, fatigue, cyanosis, possilbe clubbing of fingers; Palpation: tactile fremitus normal; Percussion: resonant; Auscultation: normal vesicular; voice sounds normal, chronic - prolonged expiration; Adventitious Sounds: crackles over deflated areas; may have wheeze

Emphysema - Condition

caused by destruction of pulmonary connective tissue (elastin, collagen); characterized by permanent enlargement of air sacs distal to terminal bronchiles and rupture of interalveolar walls; tis increases airwa resistance, especially on expiration - producing a hyperinflated lung and an increase in lung volume; cigarette smoking accounts for 80-90% of cases of emphaysema

Emphysema - Observation

Inspection: increased anteroposterior diameter; barrel chest; use of accessory muscles to aid respiration;t ripd postion; shortness of breath, especially on exertion; respiratry distress; tachypnea; Palpation: decreased tactile fremitus and chest expansion; Percussion: hyperresonant; decreased diaphragmatic excursion; Auscultation: decreased breath sounds; may have prolonged expiration; muffled heart sounds resulting from overdistention of lung; Adventitious Sounds: usually none, occasionally, wheezing

Asthma (Reactive Airway Disease) - Condition

an allergic hypersensitivity to certain inhailed allergens (pollen), irritants (tobacco, ozone), microbes, stress, or exercise that produces a complex response characterized by bronchospasm and inflammation, edema in walls of bronchioles, and secretion of highly viscous mucus into airways; these factors greatly increase airway resistance, especially during expiration, and produce the symptoms of wheezing, dyspnea, and chest tightness

Asthma (Reactive Airway Disease) - Observation

Inspection: during sever attack: increased respiratory rate, shortness of breath with audible wheeze, use of accessory neck muscles, cyanosis, apprehension, retraction of intercostal spaces; expiration labored, prolonged; when chronic, may have barrel chest; Palpation: tactile fremitus decreased, tachycardia; Percussion: resonant, may be hyperresonant if chronic; Auscultation: diminished air movement; breath sounds decreased, with prolonged expiration; voice sounds decreased; Adventitious Sounds: bilateral wheezing on expirtion, sometimes inspiratory and expiratory wheezing

Pleural Effusion (fluid) or Thickening - Condition

collection of excess fluid in the intrapleural space, with compression of overlying lung tissue; effusion may contain water capillary fluid (transudative), protein (exudative), purulent matter (empyemic), blood (hemothorax), or milky lymphatic fluid (chylothorax); gravity settles fluid in dependent areas of thorax; presence of fluid subdues all lung sounds

Pleural Effusion (fluid) or Thickening - Observation

Inspection: Increased respirattions, dyspnea; may have cough, tachycardia, cyanosis, abdominal distention; Palpation: tactile fremitus decreased of absent; tracheal shift away from affected side; chest expansion decreased on affected side; Percussion: dull to flat; no diaphragmatic excursion of affected side; Auscultation: breath sounds decreased or absent; voice sounds decreased or absent; when remainder of lung is compressed near the effusion, may have bronchial breath sounds over compression along with bronchophony, egophony, whispered pectoriloquy; Adventitious Sounds: none

Heart Failure - Condition

pump failure with increasing pressure of cardiac overload causes pulmonary congestion or an increased amount of blood present in pulmonary capillaries; dependent air ascs are deflated; pulmonary capillaries engorged; bronchial mucosa may be swollen

Heart Failure - Observation

Inspection: increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, pallor in light-skinned people; Palpation: skin moist, clammy; tactile fremitus normal; Percussion: resonant; Auscultation: normal vesicular; heart soudns include S3 gallop; Adventitious Sounds: crackles at lung bases

Pneumothorax - Condition

free air in pleural space causes partial or complete lung collapse; air in pleural space neutralizes the usual negative pressure present; thus lung collapses; usually unilateral; can be 1)spontaneous (air enters pleural space through rupture in lung wall, 2) traumatic (air enters through opening or injury in chest wall or 3) tension (trapped air in pleural space increases, compressing lung and shifting mediastinum to the unaffected side)

Pneumothroax - Observation

Inspection: uneaqual chest expansion; if large, tachypnea, cyanosis, apprehension, bulging in interspaces; Palpation: tactile fremitus decreased or absent; tracheal shift to opposite side (unaffected side); chest expansion decreased on affected side; tachycardia, decreased BP; Percussion: hyperresonant; decreased diaphragmatic excursion; Auscultation: breath sounds decresed or absent; vice sounds decreased or absent; Adventitious Sounds: none

Pneumocytis jiroveci (P. carinii) Pneumonia - Condition

this virulent form of pneumonia is a protozoal infection associate w/AIDS; parasite P. jiroveci is common in US and harmless to most people, except to the immunocompromised, in whom a diffuse interstitial pneumonitis ensues; cysts containing the organism and macrophages form in alveolar space, alveolar walls thicken, and the disease spreads to bilateral interstitial infiltrates of foamy, protein-rich fluid

Pneumocytis jiroveci (P. carinii) Pneumonia - Observation

Inspection: anxiety, SOB, dyspnea on exertion, malaise are common; also tachypnea, fever, a dry nonproductive cough; intercostal retractions in children; cyanosis; Palpation: decreased chest expansion; Percussion: dull over areas of diffuse infiltrate; Auscultation: breath sounds may be diminished; Adventitious Sounds: crackles may be present but often are absent

Tuberculosis - Condition

inhalation of tubercle bacilli into alveolar wall starts: 1) initial comple is acute inflammatory response - macrophages engulf bacilli but do not kill them; tubercle forms around bacilli; 2) scar tissue forms, lesions calcifies and shows on x-ray; 3) reactivation of previously healed lesion; dormant bacilli n ow multiply, producing necrosis, cavitation, and caseous lung tissue (cheeselike); 4) extensive destruction as lesion erodes into brochus, forming air-filled cavity; apex usally has the most damage

Tuberculosis - Observation

Subjective: initially asymptomatic, showing as positive skin test or x-ray; progressive TB involves wieht loss, anorexia, easy fatigability, low-grade afternoon fevers, night sweats; may have pleural effusion, recurrent lower respiratory infections; Inspection: cough initially nonproductive, later productive of purulent, yellow-green sputum, may be blood tinged;dyspnea, orthopnea, fatigue, weakness; Palpation: skin moist at night from night sweats; Percussion: resonant initially; dull over any effusion; Auscultation; normal or decreased vesicular sounds; Adventitious Sounds: crackles over upper loabs common, following full expiration and cough

Pulmonary Embolism - Condition

undissolved matierial (thrombus or air bubles, fat globules) orginating in legs or pelvise detach and travel through venous system returing blood to right heart and lodge to occlude pulmonary vessels; over 95% arise from DVT in lower legs as result of statis of blood, vessle injury, or hypercoagulability; pulmonary occulsions result in oschemia of downstream lung tissue, increased pulmonary artery pressure, decreased cardia output, hypoxia; rarely, a saddle embolus in bifurcation of pulmonary arteries leads to sudden death from hypoxia; more often, small to medium pulmonary branches occlude, leading to dsypnea; these may resolve by fibrolytic activity

Pulmonary Embolism - Observation

Subjective: chest pain, worse on deep inspiration, dyspnea; Inspection: apprehensive, restless, anxity, mental status changes, cyanosis, tachypnea, cough, hemoptysis, PaO2 <80%; arterial blood gasses show repiratory alkalosis; Palpation: diaphoresis, hypotension; Auscultation: tachycardia, accentuated pulmonic component of S2 sounds; Adventitious Sounds: crackles, wheezes

Acute Respiratory Distress Syndrome (ARDS) - Condition

an acute pulmonary insult (trauma, gastric aid aspiration, shock, sepsis) damages alveolar capillary membrane, leading to increased permeability of pulmonary capillaries and alveolar epithelium and to pulmonary edema; gross examination (autopsy) would show dark red, firm, airless tissue, with some alveoli collapsed, and hyaline membranes lining distended alveoli

Acute Respiratory Distress Syndrome (ARDS) - Observations

Subjective: acute onset of dyspnea, apprehension; Inspection: restlessness, disorentation, rapid, shallow breathing; prductive cough, thin, frothy sputum; retractions of intercostal spaces and sternum; decreased PaO2, blood gasses show respiratory alkalosis, x-ray show diffuse pulmonary infiltrates; a late sign is cyanosis; Palpation: hypotension; Auscultation: tachycardia; Adventitious Sounds: crackels, rhonchi

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