Anatomy of the chest
o Bony thorax
 Bony structures
 Sternum; manubrium, body, xiphoid process
 Joints - body with manubrium
 Marks attachment of 2nd ant rib; used as the
landmark/focus point
 7 pairs of ribs directly attached to sternum
 True ribs
 False ribs - not attached to any anterior structure
 12 pairs all in all
 12 - 9 = 3 pairs of false ribs
 Reason why 8,9,10 false - no direct
attachment to sternum but to rib above
them
 Costal angle
 Attachment of ribs to sternum  Inflammation; where pain is involved; sudden
stretching/activity
o Clavicle
 Prominent structure seen when you examine the chest wall
Back
o Scapula
 Inferior angle used to identify 7th posterior rib as point where
 Anteriorly use 2nd anterior
o Why anterior/posterior
 Level of rib post not same level anteriorly
 Trace it backwards posterior is higher
 Pos more horizontal/anterior oriented obliquely
o Spinus processes
 At the back, the most prominent is C7
 T1 below
 Rib attachment to 1st vertebrae is the 1st rib
o Can't palpate for the vertebrae but the spinus process
o Use bony structures to project the lungs within thoracic cage to
ant/post chest wall
Anterior
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o
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Look for sternal angle
 Where trachea bifurcates
 Post --level of the 4th spinus process
Also draw imaginary line from bony structure or soft tissues of chest
wall
 Anteriorly --draw sternum in halves
 Mid sternal line
 Divide clavicle into 2 halve
 Mid clavicular line - both left and right
 At lateral chest wall, line based on the soft tissues
 Elevate the arm, see folds - ant/post
 Ant folds - anterior axilary line
 Pos folds - post axillary line
When you elevate the arm, look into axila
 You'll see apex - like a pyramid
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o
Draw line down - mid axilary line
 Important to identify different
structures/examination
 Surgery - need structures when you do
incision/where you insert needle
Posteriorly
 Divide vertebrae into 2 equal halves
 Border - paravertebral line
 Connect anterior/sup scapular process to pos
 Scapular line
Project different fissures of lungs
o Using the bony structures
o Right lung
 3 lobes
 Oblique (major)
 Horizontal (minor)
o Left
 2 lobes
 Oblique (major)
o Fissure
 Locate spinus process t3
 Make line going laterally and downward and at level of
mid axillary line
 At level of 5th rib
 Go further medially and downward/fissure
ends at 6th ant rib midclavicular line on
right or left side (depending on which
lung)
 Right lung has horizontal fissure
 Start at the 5th rib mid ax line ---going ant and medially
following course of 4th ant rib until its attachment to the
sternum
Tracing of the lung
o At the mid para sternal line
 Parasternal line -- draw lung/drawing it upward to the clavicle
and 2 cm above the clavicle -----> apex of the lung
 Trace it down into lateral chest wall up to the 10 vert ---resting
level of diaphragm
Physical examination
o Inspection
 Don't just inspect the chest wall when pt has problem of
chest/lung
 Look at the face
 Changes seen - change in the color
 Lack oxygen - become bluish; if lips turn blue, pt
has problem with oxygenation; most likely it
involves the lungs
 Expression of pt
 Anxious or relaxed
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Short of breath/difficulty of breating --anxious
 Pain --anxious
Level of consciousness --LOC --conscious
or unconscious
 Involves cns; lack of o2 or too
much co2 also affects cns ---pt
presents alterations of
consciouness
Ala nasi
 Sight of nose --difficulty of breathing ----flaring
out especially among pediatrics
Purse lip breathing
 Purse lips when you whistle
 Some pts breathing thru purse lips --more
exhaling
 Inhale thru nose, exhale thru mouth in a
purse lip way
 Seen in pts with emphysema -disease under COPD - chronic
obstructive pulmonary disease
 Sign of sig airway obstruction --usually from
emphysema
posture
Sitting comfortably
Seating up straight or stooping forward
Sitting in one chair
 Hand at back of chair; if pt assumes this position
and has lung problem --confirm difficulty of
breathing ---position helps expansion of the chest
wall ---inhale --rib goes out and elevates ----in
physio - breathing topic --bucket handle example
-----eases even more the movement of ribs
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Body
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Weight
 Blue bloater
 Bloated
 Aka chronic bronchitis -- pt usually overweight
and rather bluish --lack o2 and short of breath
 Pink puffer
 Pink, puffing - short of breath
 Pt usually very thin -- Emphysema patients
 Emphysema - under COPD
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Neck
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If trachea in the middle or deviated
If deviated, something pushing/pulling trachea
Jugular vein
 Measure JVP
 Pts with heart failure --esp right --expect jvp distended
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Pt with lung disease --if intrapleural pressure
builds up --also have extension of jugular vein -due to obstructive lung disease (asthma, COPD,
pneumothorax, pleural effusion)
Chest proper
 Look at the chest wall
 Shape - normal or abnormal
 Normal shape
 Elliptical - anterior/posterior diameter is shorter
than lateral diameter
 Abnormal shape
 Barrel chest - ant/pos diameter almost equal
lateral diameter
 Funnel chest --pectus excavatum
 Sternum is flat structure
 With funnel chest, sternum is depressed  Protuding sternum
 Like a pigeon
 Aka pigeon chest aka pectus caranatum
 Pathology of spine
 Problem with chest
 Kyphosis - -exaceration of pos curvature
of the spine
 Hunchback
 Scoliosis
 Lateral deviation of the spine
 Standing face to face --spine
should be straight
 Scoliosis
 Lateral curvature --causing chest
wall to be abnormal as wall
 Sustained trauma
 Vehicular
 Trauma --pt involved in a fight -mult rib fracture
- Frail chest - due to mult rib fracture
 Any pt comes in with difficutly of breah -history of trauma - frail chest signs
 Take note of movement of chest
wall
 Normally when you inhale, chest
wall goes out --inhale -chest wall in
 Frail chest --inhale --move
out
 Opposite direction
movent
 Symmetry of wall
 To see if frail chest or not
 Not only bony thorax itself
 Angle formed by ribs
 Normally 45 degrees
 Copd - angle more horizontal - barrel chest
 Muscle development
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 Hypertrophy
Breathing pattern
 Normally breathe in ---chest wall moves out
 Inhale --chest wall out --ab wall out
 Pt --chest wall out --ab wall in ---abnormal respiratory alternam
 Sign of respi muscle fatigue
 Seaso pattern?? Of breathing
Respiratory alternates
 ….???
Depth of breathing
 Bulging of intercostal space
 Retraction of intercostal space
Rate of pt's breathing
 Pattern of breathing of pt
Normal breathing
 12-20 per minute
 Every hour --take deep breath 7 times
Tachypnea
 Inc rate not depth
Apnea
 Absence of breathing
Hypopnia
 Dec rate of breathing
Irregular
 Heinz stop - regularly irregular type
 Periods of apnea occure reg
Irregulary irreg
 Don't know when apnea sets in
Kuzmol
 Very fast, deep
 Seen among pts with acidosis
 Pts with severe hemorrhage
Apneustic
 Long gasping with hardly any expiration
 Pt has lesion affecting the hemotactic center --in
pons (part of brain stem
Take vital signs
 Take note of these abnormal changes
 Not just respi rate
I E ratio
 I - inspiration
 E - exhalation
 Ratio
 1:2
 1 second inhalation
 2 sec exhalation
 Prolonged exhalation phase
 Sign of airway obstruction
 2 signs - prolonged ie, purse lip
 Lots of difficulty of breathing (dob)
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Skin
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Flaring, inc respi rate, respi alternans,
seaso patter
Signs of retractions --use of accessory m
of breathing
Color --pinkish or bluish
Take note of finger
 Nicotine stained or not
 Tells you pt is a heavy smoker
 Clubbing of finger
 Normally - nail bed is indented
 Form angle
 When you put fingernails opposed -supposed to see hole --if hole
disappears --clubbing of finger --no
angle at finger --but bulging of the
finger nail bed instead of being
indented
 Sign of underlying lung problem
 Lung cancer, pul fibr,, pul
av malformation,
neurogenic diaphragmatic
tumore
 Congenital cyanotic heart disease
 Some babies born with heart
problem
 Not all inborn heart problem
will cause pt to become
cyanotic
 Not all babies with
heart --are blue
 Sub-acute bacterial
 Also clubbing
 Hepatic cirhossis, …others
 Also clubbing
 hemiplegia
Palpation
 Try to verify findings of inspection
 Position of trachea
 Lagging of chest wall
 Presence of tenderness
 Fracture or not
 For presence of masses, subcutaneous emphysema, palpate
wall --see if pt sweating profusely
 Try to measure the chest wall expansion
 Normal female --expand as much as 3 cm
 Male --4-6 cm --end inhalation --maximally
 Exhale maximally --measure it
 Difference
 For tenderness
 Costochondral junction
 Along ribs
 For subcut emp
Collecdtio of air in sub q tissues --soft and crackling (like
rubbing hair against each other
Palpation
 Spread hand like a butterfly
 Put thumb along paravertebral in posterior
 Hold chest firmly
 Ask pt to inhale/exhale
 Inhale --wall expands --thumb moves away from
midline
 Mid vertebral line --both thumbs moves
away equally
 If one thumb moves less -- that
side is lagging
 Site lagging --site where you have
problem
 For phrenitus
 Use the base of the hand/palm
 Place it on the chest wall
 Ask pt to make repetitive sound that are
low-pitched
 Say "tres tres"
 Bates -- say "99"
 Tiawanese - "ong ong"
 Say it in even voice
 It will affect the vibration
 Finger placement
 Anteriorly --ab region
 Posteriorly - shoulder (axilla)
 Feel at same time --see If equal
 One side - stronger
 If one side decreased --that side is
pathological
 Increased abnormally pathological also
 Causing consolidation
 Pneumonia
 Dec phrenitus
 Dec airflow conditions
 Airway obstruction  Inc distance btw airway and lungs and
chest wall
 Collcti of air, fluid, within pleural
cavity, thickening of pleura ---pt
overly obese --very thick wall - Overly obese
 Phrenitus decreased evenly
 Palpate for midline structure
 Trachea/pmi
 Pmi - position of heart --deviated or not
 Mediastinum
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Percussion
 Indirect percussion
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Fleximeter --finger placed on chest wall
 Over the intercostal space
 Use either index finger or middle fingerf
 Flexor - one percussing
 Should be the right hand; if left-handed,
use left hand
 Flexor --dominat hand
Fleximeter
 Non-dominant hand
Action
 At the wrist
Strike
 Strike the distal interphalanges
 Not nail, nailbed
Listen to the sound you create
 Dull? Resonant?
 Flat? Tympanating
Normal percussion
 Resonance
 When dull, tymp, hyper, flat --abnormal
Normal example of flat note
 Thigh
Liver
 Dull
Abdomen
 Hyper resonance
 Distended abdnomen - retention of air
 Tympanic
Chest
 Without problem ---resonant sound
 Flatness - massive pleural effusion,
pneumonectomy - removal of lung
 Dull
 Neoplasm, fibrosis, thickening of pleura,
enlarged heart
 Hyper resonance
 Emphysema, pneumothorax, acute
exacerbation of asthma
 Tympanitic
 Massive hemothorax, tension
pneumothorax, percussing over enlarged
pulmonary artery
Identify resting level of diaphragm
 How much it descends on max inspiration
 As much as 2 interspace or 6 cm
Resonant note
 Take note of pitch, not the loudness
Area of percussion
 Also area of auscultation
 Anteriorly
 Clavicle, 2-4 ribs
 Posteriorly
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o
2-5 ribs
 Direct not done anymore
Auscultation
 Listen to different
 Presence/absence of breath sounds
 Intensity of breath sounds
 If sounds inc/dec
 Vocal phremitus of pt
 Normal breath sounds
 4 normal
 Chest wall
 2 normal
 Vesicular
 Relatively soft, low-pitched
 Longer inspiratory phase
 Heard all over chest wall except where you hear
bronchovesicular sounds
 Pitch in medium range
 Bronchovesicular breath sounds
 Pitch in medium
 Heard over intrascapular area pos
 Anterior 1st/2nd intercostal space ant ches
 Bronchiole
 Not normally heard
 Over manubrium --area where you don't
auscultate
 High-pitched, loud
 Trachial
 Loud, high pitched
 Over tracheal area outside thoracic cage
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Supraclavicular area
 Lung extends above the clavicle
 Above 2nd 3rd inner clavicle
Abnormla/breath sounds aka adventitious
 Continuous
 Lasts for very short period of time
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As long as 25 milliseconds
Wheezes, ronchi, stridor
 Wheezes -high-pitched, hissing quality
 Asthmatics - noise from chest wall
 Described as whistle
 Auscultate chest --hear whistle
 Denotes small airway obs
Ronchi
 Low-pitched
 Snoring quality - like boiling water
Stridor
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Similar to wheezes
Mainly inspiratory; tells you that
obstructin in the large airway (trachea, r, l
main stem bronchus)
Friction
 Leathery sound --syncrhonous to
breathing of pt
 Confined to small area of chest wall
Mediastinal crunch
 Hammond's sign
 Pts with pneumo-mediastinum
 Air in the middle of the chest wall
 Serial of precordial crackle
 Best heard in left lateral postiton --tells
you it's an emergency
Abnormal
 Right upper lung field
 Or post right base
 Anterior left base
 Tell us where you hear the abnormal
sound
 If you hear normal breath all over, but
hear broncho air sounds --abnormal -take note
 Even if it's normal breath sounds --if
heard outside its normal location then it's
an abnormal finding
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Intensity of breath sounds
 Decreased
 Dec air movement (rest lung disease)
 Inc insulation btw airway and wall
 Increase intensity
 Any condition that causes consolidation
 That decreases tactile phremitus
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Discontinuous
 < 25 seconds
 Crackles or rales
 Signifies secretions in the alveoli or respiratory
bronchiole
Vocal phremitus
 Ask pt to say something using stethescope
 Normally muffled -not clear
 If it's very clear ---bronchophony
 Inc distinction of spoken words ---consolidation
 Positive broncophony --consolidation
 Whisper --very clear --positive whisper --….
 Ask pt to say "e"
 Muffle normally
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If "e" sounds like "a" --consolidation --auscultating over consolidating lungs above level
of pleural effusion
o
Unlike
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heart
Inspect, palpate, aus --don't percuss
Sinuses - don't auscultate at all
Next sem - abdomen
 Inspect, aus, palpate, perscuss = change in sequence
o
Diseases
 Table in Bates
 Pt with pleural effusion
 Pt with pneumothorax difference
 Difference in percussion
 And ..???
 Shifting of mediastinum
o
o
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Included because it's located over the thoracic cage
Secondary sexual sign
Born --not fully developed
 Develops pre-adolescent age -fully developed at ado
 Full -from 2nd ant rib to 6th
 From sternal area to mid axillary line
 Sometimes pt complains of fullness of axilla when have
ovulation
12 lobules
 Separated from each other by fibrous tissue
Nipple
 Examine - multiple small holes for drainage of milk
Main concern with regards to breast
 2ndry sex sign
 Breast cancer ---main concern
 In US, number one cause of death
 Mastitis
 Infection of breast; more common when breastfeeding -drying of nipple from sucking of baby increasing
infection due to cracking
Risks for development of breast cancer
 Family history
 1st degree relative  1.2- 3 %
 Timing
 If post menopausal, risk lesser compared to premenopausal
 Lateral
 Higher than unilateral
 Menstrual
 Early menarche --inc risk
Breast
o
o
o
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Later menopause
 Inc
Early pregnancy
 Risk of having breast cancer decreases
Late preg
 Or never gave birth --risk higher
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Breast conditionst
 Non-maligant breast condition --inc
 Lobular carcinoma --12% risk
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Family history
 Japanese - rare breast cancer
 But Japanese living in America have inc risk of
breast cancer
 Fatty food
 Inc risk of breast cancer
Age
 The older you are, higher the risk to develop
 15-20
 Fibro adenoma - benign
 25-50
 If soft --cyst --benign
 Irregular, firm, no clear border --malignant
chance higher
 Over 50
 Able to palpate breast
 Always consider malignancy before considering
other lesions
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o
Screening for breast cancer
 Self-examination
 Age
 As early as 20
 Clinical
 20 - if pt high risk
 If not high risk
 30
 Breast exam by a physician
 If not high risk
 Every 3 years from 20-39
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o
Mammography
 After 40 every year
 1st mammo --35 yrs old (increased risk)
Exam
 Inspection
 Look at appearance of skin
 Size, symmetry of breast
 Assymetry - sign of malignancy
 Due to change in contour of breast
 Nipple
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Skin
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Size, shape, rashes, discharge coming from
nipple
Changes ----presence of scale, eczema like lesion
--rare cancer of nipple -Pageat's disease ---skin -edema of skin --orange-peel skin --lower
quadrant of breast due to obs of lymphatic spine
of tumor cell
Draw horizontal and vertical line crossing nipple
 Anything below horizontal line --lower
quad
 Above --upper quad
 Inner upper quad
 Near the sternum -inner
 Axilla ---outer
 Outer upper quad
 Inner lower quad
 Outer lower quad
 Changes in skin --edema --seen in
lower quadrant
 Aka orange peel skin
Malignancy --retraction of nipple
 Invasion of tissue cell from fibrous tissue -shortening --retracting the nipple
 Retracted nipple --ask pt --know
nipples are retracted == if pt tells
you nipple retracted ling time ago -not inborn problem ---sign of
malignancy
Dimpling of the breast
 Change in the contour
 Example
 Apple --if it fell down and it surface
--pick it up -still whole --after 2
days --look at apple --there's a
dent
 In the breast, if dent --dimpling
 By siimple inspecti --may not see dimpling
---so you do maneuver ---ask pt to strtch
out both hands --reach the ceiling --cause
contraction --bringing out the dimpling
 Put hands on hips --press on hips --brings
out dimple
 If pt has pendulus breast --have pt sigt on
chair --arm resting on arm of chair --lean
forward --bring out dimpling
Palpation
 Want the patient to lie down
 With small pillow at outer back
 Hand of pt above the head/under the head
 Right breast --right hand above;
 Time examination of breast
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Done
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o
Not done when pt ovulating ---breast will be
engorged
Ideally ---7th day after the first menstrual flow
 Example
 Flow on Oct 1 --examine breast Oct
7
 First week of menstrual
cycle
in systemical order
Nipple --take note whether or not discharge
 Bloody discharge
 Pt has malignancy --disease of
nipple --pt has adenofibrous
sarcoma, malig malanoma,
neurosarcoma…..
 Seroud dicharge
Lactating
 Milk coming out of nipple ---abnormal
 Any trauma to the breast --abnor
 Pneumonect, teracotomy,
carper's sauster
 Pituitary disorder --tumor in
piuitary --prolactemo
 Hormonal
 Hypothyroidism
 Hyperthyroidism
 Intake of tranquilizera
 phenothalozine
 Only lactate when you're pregnant/gave
birth child
7th day of menstrual
 Inspection --seated
 Palpation
 Normal nodularity decreased
 3 techniques of exam
 Circulation --from outer circle going in
 Inner
 From sternal area --to axillary area
 Linear
 Palpate downward, upward, down
again, up again
 Until you reach the nipple
 recommended
 Palpate in circular motion
 Whatever technique you use
Lymphatic drainage
 Anterior
 Most important
 Along lower border of pec major inside ant ax fold
 Drains ant chest wall and most of breast
 Consistency
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 Like nose
If mass
 Location, if right or left breast, inner/upper quad,
lower/outer
 Size
 Shape
 Consistency
 Mobility
 Tender or not
 Malignant mass usually NON tender
immobile, poor border, hard
 Sometimes stony hard --shape usually
irregular
 Size
 3 cm
Treatment
 Removal of the mass
 Make sure it's malignant first
 Do fine needle aspiration
Posterior
 Subscapular
 Lat border of scapular  Drain most of post wall/portion of arm
Lateral
 Upper humorous
Central
 High in axilla, mid ax fold