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  1. Anatomy of the chest wall
    Image Upload 1
  2. How are the interspaces located in rapport to the ribs
    • 1st rib
    • 1st interspace
    • 2nd rib
    • 2nd interspace
    • etc ...
  3. At what level of the chest is the sternal angle located?
    2nd ribs
  4. Where is the suprasternal notch located?
    in the middle of the clavicles
  5. Where is the manubrium located?
    between the suprasternal notch and the sternal angle ( 5cm from one another)
  6. where do the costal cartilages of the 1st 7 ribs articulate?
    with the sternum
  7. Where do the cartilages of the 8th,9th,10th ribs articulate?
    with the costal cartilage just above them
  8. What is so special about the 11th and 12th rib?
    they are called the "floating ribs" bc they have no attachments
  9. Where can the 11th rib cartilaginous tip usually be felt?
  10. Where can the 12th rib be felt?
  11. How do costal cartilages and ribs feel on palpation?
  12. 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
  13. Where does the tip of the scapula lie?
    level of the 7th rib or interspace
  14. When the neck is flexed, which spinous processes are the most protruding?
    C7 and T1
  15. 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
  16. lungs and lobes?
    • RL - 3 lobes
    • LL - 2 lobes
    • horizontal fissure - 4th rib - meet oblique fissure at 5th rib

    Image Upload 2
  17. Supra/Infraclavicular?
    above and below the clavicles
  18. Inter/Infrascapular
    between and below scapula
  19. Where does the trachea bifurcates into its mainstream bronchi?
    • at the sternal angle anteriorly
    • T4 process posteriorly
  20. Where is breathing controlled?
  21. What does a clinched fist over sthe sternum suggest?
    angina pectoris
  22. A finger pointing to a tender area on the chest wall?
    musculoskeletal pain
  23. Hand moving from neck to epigastrum?
  24. what is the most common cause of chest pain in children?
  25. What ss may you see in an anxious pt?
    • episodic dyspnea during both rest and exercise
    • hyperventilation
    • frequent sighs
  26. When is wheezing seen in a patient?
    airway obstruction from secretions, tissue inflammation or a foreign body.
  27. When is cough seen in a CV issue?
  28. When are dry and productive coughs seen?
    • Dry: mycoplasmal pneumonia
    • Productive: bronchitis, viral or bacterial pneumonia, CF
  29. When are large volumes of prurulent sputum seen?
    • bronchiectasis
    • lung abcess
  30. When does the AP diameter increase?
    with age and COPD
  31. At which rib level is chest expansion tested?
  32. When is fremitus decreased or absent?
    • fluids in the lungs
    • infiltrating tumor
    • thick chest wall
  33. Where is fremitus more prominent?
    interscapular area than lower lobes
  34. 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
  35. How do normal lungs sound? + simple chronic bonchitis
  36. Percussion note of large pleural effusion ( think thigh)
  37. 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.
  38. Hyperresonance?
    • Emphysema, pneumothorax, asthma
    • - shouldn't be heard in normal body
  39. 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.
  40. 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)
  41. Duration of sounds and location where heard normally: vesicular
    • Inspiratory> Expiratory
    • Heard over most of long field
  42. Bronchovesicular
    • I =E 
    • Often heard in the 1st and 2nd interspaces anteriorly and between the scapula
  43. Bronchial
    • E>I
    • Heard over the manubrium if heard at all
  44. Tracheal
    • I=E
    • Over the trachea in the neck.
  45. 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)
  46. What does a silent gap suggest between I and E?
    bronchial breath sounds.
  47. What does increased transmission of voice suggest?
    air-filled lungs has become airless
  48. Define bronchophony
    when sound transmitted through chest wall is clear ( normally they should be muffled)
  49. 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
  50. Whispered pectoriloquy?
    ask pt to whisper 99, whispers normally heard vaguely if at all. - Abnormal: louder and clearer sounds.
  51. 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)
  52. 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
  53. 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
  54. Define Barrel chest
    • AP> 
    • normal during infancy and often accompanies normal aging and COPD
  55. Traumatic flail chest?
    • Inspiration: injured area moves inward
    • Expiration: injured area moves outward
  56. funnel chest? ( Pectus excavatum)
    • depression in the lower portion of the sternum
    • compression of the heart and great vessels can cause murmursImage Upload 3
  57. Pigeon chest ( pectus carinatum)?
    • sternum is displaced anteriorly --> AP inc.
    • Costal cartilages adjacent to the protruding sternum are depressed.Image Upload 4
  58. Thoracic Kyphoscoliosis
    • chest is deformed by abnormal spinal curvatures and vertebral rotation 
    • listening to the lungs may be difficultImage Upload 5
  59. 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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