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Anatomy of the chest wall
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How are the interspaces located in rapport to the ribs
- 1st rib
- 1st interspace
- 2nd rib
- 2nd interspace
- etc ...
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At what level of the chest is the sternal angle located?
2nd ribs
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Where is the suprasternal notch located?
in the middle of the clavicles
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Where is the manubrium located?
between the suprasternal notch and the sternal angle ( 5cm from one another)
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where do the costal cartilages of the 1st 7 ribs articulate?
with the sternum
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Where do the cartilages of the 8th,9th,10th ribs articulate?
with the costal cartilage just above them
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What is so special about the 11th and 12th rib?
they are called the "floating ribs" bc they have no attachments
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Where can the 11th rib cartilaginous tip usually be felt?
laterally
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Where can the 12th rib be felt?
posteriorly
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How do costal cartilages and ribs feel on palpation?
identical
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What are the 2 starting points for counting ribs and interspaces?
and some other anatomic landmarks?
- suprasternal notch - (manubrium)- sternal angle - 2nd rib
- 12th rib
- Some other anatomic landmarks:
- - scapula - 7th rib poteriorly
- - spinous processes
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Where does the tip of the scapula lie?
level of the 7th rib or interspace
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When the neck is flexed, which spinous processes are the most protruding?
C7 and T1
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Where does the lower border of the lung crosses?
- 6th rib at the midclavicular line
- 8th rib at the midaxillary line
- level of T10 spinous process posteriorly
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lungs and lobes?
- RL - 3 lobes
- LL - 2 lobes
- horizontal fissure - 4th rib - meet oblique fissure at 5th rib
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Supra/Infraclavicular?
above and below the clavicles
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Inter/Infrascapular
between and below scapula
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Where does the trachea bifurcates into its mainstream bronchi?
- at the sternal angle anteriorly
- T4 process posteriorly
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Where is breathing controlled?
Brainstem
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What does a clinched fist over sthe sternum suggest?
angina pectoris
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A finger pointing to a tender area on the chest wall?
musculoskeletal pain
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Hand moving from neck to epigastrum?
heartburn
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what is the most common cause of chest pain in children?
anxiety
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What ss may you see in an anxious pt?
- episodic dyspnea during both rest and exercise
- hyperventilation
- frequent sighs
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When is wheezing seen in a patient?
airway obstruction from secretions, tissue inflammation or a foreign body.
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When is cough seen in a CV issue?
LSHF
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When are dry and productive coughs seen?
- Dry: mycoplasmal pneumonia
- Productive: bronchitis, viral or bacterial pneumonia, CF
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When are large volumes of prurulent sputum seen?
- bronchiectasis
- lung abcess
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When does the AP diameter increase?
with age and COPD
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At which rib level is chest expansion tested?
10th
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When is fremitus decreased or absent?
- fluids in the lungs
- infiltrating tumor
- thick chest wall
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Where is fremitus more prominent?
interscapular area than lower lobes
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What are the things that you can and cannot detect with percussion of the lungs?
- Can: help establish whether underlying tissues are filled with air, fluid-filled or solid.
- Cannot: help detect deep seated lesions
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How do normal lungs sound? + simple chronic bonchitis
Resonant
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Percussion note of large pleural effusion ( think thigh)
flatness
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Lobar pneumonia? ( think liver)
dullness - which replaces resonance when fluid or solid tissue replaces air-conditioning lung or occupies the pleural space beneath your percussin fingers.
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Hyperresonance?
- Emphysema, pneumothorax, asthma
- - shouldn't be heard in normal body
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Tympany? ( think gastric air bubble or puffed out cheek)
- large pneumothorax
- also heard as you percuss down the chest on the left, the resonance of normal lung usually changes to the tumpany of the gastric air bubble.
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How do you determine the extent of diaphragmatic excursion?
by determining the distance between the level of dullness on full expiration and the level of dullness on full inspiration ( normally about 5-6 cm)
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Duration of sounds and location where heard normally: vesicular
- Inspiratory> Expiratory
- Heard over most of long field
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Bronchovesicular
- I =E
- Often heard in the 1st and 2nd interspaces anteriorly and between the scapula
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Bronchial
- E>I
- Heard over the manubrium if heard at all
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Tracheal
- I=E
- Over the trachea in the neck.
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If bronchial and bronchovesicular sounds are heard further away from the aforementioned area, what shoud be suspect?
fluid filled lungs or solid lungs (exudate filled lungs)
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What does a silent gap suggest between I and E?
bronchial breath sounds.
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What does increased transmission of voice suggest?
air-filled lungs has become airless
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Define bronchophony
when sound transmitted through chest wall is clear ( normally they should be muffled)
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Egophony?
When eee sound is heard as aaaa - normal sound is heard the same way --> also suggest area of consolidation from possible pneumonia - the quality sounds nasal
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Whispered pectoriloquy?
ask pt to whisper 99, whispers normally heard vaguely if at all. - Abnormal: louder and clearer sounds.
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Where would you percuss the heart, and what would you expect to hear?
- left of the sternum from the 3rd to the 5th interspace.
- should hear an area of dullness (hyperesonance of COPD may totally replace cardiac dullness)
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How do you identify rib fractures?
- push on sternum and thoracic spine, ask for pain
- increase in local pain and tenderness in area distant from hands suggests fractured ribs
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Forced Expiratory time?
- test in COPD - bc usually it is slow with this population
- ask pt to breath in and then out as quickly as possible, listen over the trachea with the diaphragof the stethoscope, count the time.
- Try to get 3 consistent reading with rest in between.
FET of 6 sec or more = COPD
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Define Barrel chest
- AP>
- normal during infancy and often accompanies normal aging and COPD
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Traumatic flail chest?
- Inspiration: injured area moves inward
- Expiration: injured area moves outward
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funnel chest? ( Pectus excavatum)
- depression in the lower portion of the sternum
- compression of the heart and great vessels can cause murmurs
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Pigeon chest ( pectus carinatum)?
- sternum is displaced anteriorly --> AP inc.
- Costal cartilages adjacent to the protruding sternum are depressed.
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Thoracic Kyphoscoliosis
- chest is deformed by abnormal spinal curvatures and vertebral rotation
- listening to the lungs may be difficult
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Compare Normal air filled lungs with airless lung as in lobar pneumonia
- Normal:
- - BS: vesicular
- - Transmitted voice sounds normal
- - Tactile Fremitus: normal
- Lobar pneumonia
- - BS: bronchial or bronchovesicular over affected area
- - Transmitted voice sound: egophony, whispered pectoriloquy, bronchophony
- - Tactile Fremitus" increased.
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