Review Notes

thoracic cage consists of:
-The sternum
-vertebrae
- the diaphragm (which forms the floor)
anterior thorax, surface landmarks include:

- The suprasternal notch;
- The sternum (or breastbone), which has a manubrium, body, and xiphoid process;
-The sternal angle (or angle of Louis), which is continuous with the second rib;
- the costal angle, where the right and left costal margins meet at the xiphoid process.
On the posterior thorax, surface landmarks include:

- The vertebra prominens;
- The spinous processes;
- The inferior border of the scapula, usually at the seventh or eighth rib;
- the twelfth rib.
what landmarks should be used on the anterior chest?

use the midsternal and midclavicular lines
what landmarks should be used posterior chest?

use the vertebral and scapular lines
What landmarks should be used on the lateral chest?

use the anterior axillary, posterior axillary, and midaxillary lines
apex of the lung

(the highest point) lies 3 or 4 cm above the inner third of the clavicles
The base of lung

(lower border) rests on the diaphragm at about the fifth intercostal space in the right
midclavicular line and at the sixth rib, the midclavicular line on the left
Lateral landmarks
lung extends from the apex of the axilla to the seventh or eighth rib
Posterior landmarks
C7 marks the apex, and T10 usually corresponds to the base. On deep inspiration, the
lungs expand their lower border to the level of T12.
History of Present Illness

Explore the following:
-whether the patient coughs or complains of coughing,
-the onset and nature of the cough, sputum characteristics,
- pattern and severity of the cough, associated symptoms (e.g., hoarseness), and
- efforts to treat.
Document the following data:
- whether the patient has or complains of shortness of breath,
- the onset of the problem,
- pattern and factors facilitating or relieving it, and -associated symptoms (e.g., such as
diaphoresis), and -efforts to treat.
Complaints or signs of chest pain should be noted, along with their onset and duration,
associated symptoms (e.g., fever), and any treatment efforts.
Past Medical History

Pertinent data include:
- past thoracic trauma or surgery,
-the use of oxygen,
-chronic pulmonary diseases,
-other systemic disorders (e.g., cancer),
- related respiratory tests,
-immunization against pneumonia, influenza
-the use of daily medications, both prescription and nonprescription.
Family History
A family history of:
- tuberculosis,
- cystic fibrosis,
-emphysema,
-allergies,
-smoking,
-malignancy,
-clotting disorders,
-the risk of pulmonary embolism, bronchiectasis, and bronchitis should be noted.
Personal and Social History

Work-related exposure to:
- irritants,
-allergens,
- hazards
Use of protective devices should be documented.

Environmental factors in the home include:
- type of heating,
-air conditioning,
-and humidification.
Other relevant data include:

-drug and alcohol consumption;
-tobacco use;
-exercise tolerance;
-travel history;
-potential exposure to respiratory infections, such as influenza, or tuberculosis;
-nutritional status
-weight loss or obesity
hobbies:
-owning pigeons, parrots, or other animals,
-woodworking,
- welding and exercise tolerance: diminished ability to perform up to expectations.
Self-care behaviors
When was your last TB skin test, chest x-ray study, pneumonia or influenza
immunization?
Examine the posterior thorax and lungs while the patient is
sitting
Examine the anterior thorax and lungs with the patient
supine
Compare one side of the thorax and lungs with
the other
What order should the assessment be performed in?

inspect, palpate, percuss, and auscultate
inspect
the posterior and anterior chest.
Note the:
- shape,
-configuration, and
-symmetry of the thoracic cage,
- anteroposterior ratio,
-placement of the scapulae,
-angle of the ribs, and
-development of the neck and trapezius muscles.
inspection is what type of data
objective
What are you inspecting for in relation to lungs?

-chest landmarks.
- skin, nails, and lips.
- Smell for odors of the breath.
- Count respiration rate for 60 seconds.
- Note respiratory pattern and movements.
- Inspect chest wall movement for symmetry.
What should you be inspecting in regards to respiration?
Rate - 12-20/min adult
Rhythm - regular, irregular
Depth - shallow, deep
Effort - effortless, quiet
Symmetry
Accessory muscle use
Nasal flaring
Inspect Shape of Thorax

Normal Anteroposterior Ratio = 1 : 2 (Barrel chest 1:1 r/t COPD)
Anterior Structural Deformities
Posterior Structural Deformities
Palpate the Chest

Thoracic expansion - symmetric movement
Tenderness
Crepitus
Tactile fremitus - a palpable vibration

"Say 99"
palpate anterior and posterior chest bones and muscles for

pulsations
pain
bulges
movement
depression
crepitation
positions.
Palpate tactile fremitus at bifurcation of bronchi by

using palmar surfaces of fingers or ulnar surfaces of the hand
How do you assess the trachea?
Move index fingers in suprasternal notch and inner borders of sternocleidomastoids
Why do we percuss chest?

To determine size, location, organ boundaries, density
and to map out the lower lung border and measure diaphragmatic excursion.
Where do we percuss?
anterior, posterior, and lateral chest at 4- to 5-cm intervals, moving from superior to
inferior and medial to lateral using one side as a control. Perform from side to side to
assess for asymmetry
How do we percuss?
-Strike using the tip of your tapping finger
-Use the lightest percussion that produces a clear note
-Percussion helps establish whether the underlying tissues -(5-7 cm deep) are air-filled,
fluid-filled, or solid
What sound is normal in lung fields?

resonance (hyperresonance in child's lung)
When do we hear hyperressonance?

emphysema
pneumothorax
child's lung
When do we hear dull sounds during percussion?

-pneumonia
- pleural effusion
- atelectasis
- tumor
- liver
When do we hear flat sound while percussing?

over bones
Auscultation
Auscultation of the lungs is the most important examination technique for assessing air
flow through the tracheobronchial tree
Use the pattern suggested for percussion, moving from one side to the other and
comparing symmetric areas of the lungs
Listen to at least one full breath in each location; have pt breathe deeply through an
open mouth.
Which side of the stethescope do you use to ausculatate lungs?

Diaghram
auscultation and percussion together help:

assess the condition of the surrounding lungs and pleural space
Normal vesicular breath sounds:

soft and low pitched; usually heard over most of both lungs
(peripheral lung fields)
Normal Bronchial breath sounds

louder and higher in pitch; usually heard over the manubrium (Trachea, larynx)
Normal Bronchovesicular breath sounds
intermediate intensity and pitch (medium pitch); usually heard over the 1st and 2nd
interspaces (Upper sternum, scapula)
Examples of adventitous (added) sounds

Crackles (Rales)
Fine
Course (Rhonchi)
Atelectatic crackles not pathologic
Wheezes
Pleural Friction Rubs
Stridor (blocked airway)
If you have abnormal finding in breath sounds, auscultate for

voice sounds
Voice sounds
Not done routinely
Normally hear soft, muffled, indistinct sounds
Bronchophony voice sounds

say "99"
Egophony voice sounds

"e" sounds like "a"
Whispered Pectoriloquy voice sounds

Whisper "1, 2, 3"
Examine the anterior chest by:

proceed in an orderly fashion: inspect, palpate, percuss, and auscultate
During anterior chest percussion, where will you hear dullness from heart?
to the left of the sternum from the 3rd to 5th rib interspaces
During anterior chest examination, is supraclavicular retraction often present?

Yes!
Normal Findings in an adult during thoraxic inspection:

- Anteroposterior diameter is half the size of transverse diameter.
- Respiratory rate is 12 to 20/minute.
- Ratio of respirations to heartbeat is 1:4.
- Chest expansion is equal bilaterally.
- Bronchial, bronchovesicular, and vesicular breath sounds heard on auscultation

Typical variations in an adult during thoraxic inspection:
- Decreased tactile or vocal fremitus is associated with emphysema.
- Hyperresonance indicates hyperinflation of lungs.
- Dullness indicates lung consolidation. Work-related exposure to irritants and allergens

and use of protective devices should be explored.
Findings Associated with Disorders in adults during a thoraxic exam:

- Shallow respirations are associated with injured rib, pleurisy, liver enlargement, or
abdominal ascites. Slow respirations may mean neurologic or electrolyte problems,
infection, or pleurisy.
- Barrel chest found with obstructive pulmonary disease and is associated with chronic
disease
- Asymmetric, unequal expansion of the lungs may be caused by extrapleural air, fluid,
or mass.
- Expiratory bulging may indicate enlarged heart, tumor, or aneurysm.

Chest asymmetry suggests pneumothorax.
Normal Findings in infants and children during thoraxic inspection:

- Respirations are 40 to 60/min.
Xiphoid process is prominent with sharp tip
Typical variations in infants and children during thoraxic inspection:

- Hyperresonance is common in children
- Minimal pectus carinatum and pectus excavatum may be present.
- Rales and rhonchi are common.
- Transient tachypnea is associated with cesarean birth.
- Preterm infants may have irregular respiratory rate or apneic periods.
Findings Associated with Disorders in infants and children during a thoraxic exam:
- Pursed lips indicate increased expiratory effort.
- Flared nares suggest air hunger. Chest roundness (increased anteroposterior

diameter) after 2 years of age indicates chronic obstruction.
- Gastrointestinal gurgle in chest indicates diaphragmatic hernia.
- Unilateral retractions may be caused by foreign body.

- Dry, hoarse, barking cough suggests croup. Inspiratory whoop with coughing is
associated with pertussis. Nasal flaring and intercostal, sternal, or suprasternal
retractions indicate respiratory distress
- Stridor indicates high respiratory obstruction in infants and children
Normal Findings in older adults during thoraxic inspection:

- With aging, there is loss of muscle strength of thorax and diaphragm, resulting in
decreased lung resiliency.
- Alveoli are less elastic and more fibrous.
Typical variations in older adults during thoraxic inspection:

- Older adults have less chest expansion; larger anteroposterior diameter; and marked,
bony prominences.
- Aging is associated with kyphosis, use of accessory muscles, and hyperresonance.
Findings Associated with Disorders in older adults during a thoraxic exam:

- Cheyne-Stokes respiration (periodic respiration.. periods of apnea mixed with shallow
breathing) implies serious condition.
- Chest pain should be noted along with onset, duration, and associated symptoms of
diaphoresis or shortness of breath.
What is the leading cause of preventable death in the United States
smoking
Promote smoking cessation. The concepts of exposure to secondhand smoke, also

known as environmental tobacco smoke (ETS) should be discussed. Terms such as
sidestream smoke (smoke from the burning end of a cigarette, pipe or cigar) and
mainstream smoke (the smoke exhaled from the lungs of the individual who is smoking)
should be explained to the patient.
The five A's with smoking are:
- Ask about smoking at each visit
- Advise patients regularly to stop smoking using a clear, personalized message
- Assess patient readiness to quit
- Assist patients to set stop dates and provide educational materials for self-help
- Arrange for follow-up visits to monitor and support patient progress
Atelectasis
collapsed or shrunken section of alveoli or entire lung. R/t 1) airway obstruction, 2)
compression on lung, or 3) lack of suractant. AEB: lag on one side for chest expansion,
dull percussion, decreased or absent breath sounds.
Lobar pneumonia
Infection in lung, alveolar fill with debris, fluid, bacteria and blodd cells leading to
hypoxemia. AEB: incr. RR, lag unilateral on expansion, dull percussion, voice sounds
increased clarity
Asthma
allergic hypersensitivity to inhaled allergens characterized by bronchospasm and
inflamation. AEB: increased RR, dyspnea, wheezing, labored breathing, decreased
tactile fermitus, tachycardia, resonance upon percussion, hear diminished breath
sounds, and bilateral wheezing.
Heart failure
pump failure w/ incr. blood in pulmonary, increased RR, dyspnea on exertion,
orthopnea, pallor, moist & clammy skin, resonance, heart sounds include S3, and
crackle at lung base.

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Review Notes

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thoracic cage consists of:

anterior thorax, surface landmarks include:

On the posterior thorax, surface landmarks include:

what landmarks should be used on the anterior chest?

what landmarks should be used posterior chest?

What landmarks should be used on the lateral chest?

apex of the lung

The base of lung

History of Present Illness

Past Medical History

Personal and Social History

Use of protective devices should be documented.

Other relevant data include:

What order should the assessment be performed in?

What are you inspecting for in relation to lungs?

Inspect Shape of Thorax

Palpate the Chest

Tactile fremitus - a palpable vibration

palpate anterior and posterior chest bones and muscles for

Palpate tactile fremitus at bifurcation of bronchi by

Why do we percuss chest?

What sound is normal in lung fields?

When do we hear hyperressonance?

When do we hear dull sounds during percussion?

When do we hear flat sound while percussing?

Which side of the stethescope do you use to ausculatate lungs?

auscultation and percussion together help:

Normal vesicular breath sounds:

Normal Bronchial breath sounds

Examples of adventitous (added) sounds

If you have abnormal finding in breath sounds, auscultate for

Bronchophony voice sounds

Egophony voice sounds

Whispered Pectoriloquy voice sounds

Examine the anterior chest by:

During anterior chest examination, is supraclavicular retraction often present?

Normal Findings in an adult during thoraxic inspection:

- Respiratory rate is 12 to 20/minute.

- Ratio of respirations to heartbeat is 1:4.

- Chest expansion is equal bilaterally.

- Bronchial, bronchovesicular, and vesicular breath sounds heard on auscultation

- Hyperresonance indicates hyperinflation of lungs.

- Dullness indicates lung consolidation. Work-related exposure to irritants and allergens

Findings Associated with Disorders in adults during a thoraxic exam:

- Expiratory bulging may indicate enlarged heart, tumor, or aneurysm.

Normal Findings in infants and children during thoraxic inspection:

Typical variations in infants and children during thoraxic inspection:

- Minimal pectus carinatum and pectus excavatum may be present.

- Rales and rhonchi are common.

- Transient tachypnea is associated with cesarean birth.

- Preterm infants may have irregular respiratory rate or apneic periods.

- Flared nares suggest air hunger. Chest roundness (increased anteroposterior

- Gastrointestinal gurgle in chest indicates diaphragmatic hernia.

- Unilateral retractions may be caused by foreign body.

- Stridor indicates high respiratory obstruction in infants and children

Normal Findings in older adults during thoraxic inspection:

- Alveoli are less elastic and more fibrous.

Typical variations in older adults during thoraxic inspection:

- Aging is associated with kyphosis, use of accessory muscles, and hyperresonance.

Findings Associated with Disorders in older adults during a thoraxic exam: