Surface Anatomy of Thorax

Question 1

How do you assess surface anatomy of the thorax during a physical exam?

Answer 1

-Observe symmetrical breathing patterns
-Identify correct landmarks for stethoscope placement

Question 2

What are the bony landmarks on the anterior view of the thorax?

Answer 2

-jugular (sternal) notch (JN)
-sternal angle (SA)
-2nd rib
-intercostal spaces 2-6 (ICS)
-costal margin (CM)

Question 3

What is the jugular (sternal) notch (JN)? How would you describe it anatomically?

Answer 3

Top notch of the manubrium, easy to identify, good starting point for palpation

Question 4

What is the sternal angle (SA)? How would you describe it anatomically?

Answer 4

Raised bump in between body of sternum and manubrium

-Behind it, trachea does it’s first split/bifurcated into left and right primary bronchi
-Location where the aortic arch is going up and over (beginning and end of aortic arch)
-Palpation of the SA helps you find the second rib

Question 5

What is the 2nd rib? How would you describe it anatomically?

Answer 5

Found on side of the sternal angle,
Good place to start finding the intercostal spaces!

Question 6

What are the intercostal spaces (ICS)? How would you describe them anatomically?

Answer 6

Spaces in between ribs
-if you can find the second, you can find the others and use them for auscultation points/procedures

Question 7

What is the costal margin (CM)? How would you describe it anatomically?

Answer 7

The costal cartilage along the bottom of the anterior ribs (there are two of them, right and left)

Question 8

What is the subcostal angle (SCA)? How would you describe it anatomically?

Answer 8

Angle formed by the two costal margins on the anterior ribs

Question 9

What are the bony landmarks on the posterior view of the thorax?

Answer 9

-costovertebral angle (CVA)
-spinous processes of thoracic vertebrae 1-12

Question 10

What is the costovertebral angle (CVA)? How would you describe it anatomically?

Answer 10

Junction formed by the 12th rib and vertebral column
-good place to assess symmetry of ribs when breathing
-kidneys located deep to CVA on each side, if pathology is going on there will be tenderness in the CVA (kidney punch test to assess for tenderness)

Question 11

How do you describe the inferior borders of the lungs from a POSTERIOR view?

Answer 11

Lungs do not go down to the 12th rib, located along the horizontal line of the 10th rib (T10)

Count up from T12 to T10 spinous processes for a ballpark starting point to find base of the lungs for auscultation

Question 12

How do you describe the inferior borders of the lungs from a LATERAL view?

Answer 12

Inferior border will start at 10th rib and span along to about the 8th rib (as the ribs wrap around at a diagonal level)

Question 13

How do you describe the inferior borders of the lungs from an ANTERIOR view?

Answer 13

Inferior border will start at 8th rib and span along to costal cartilage of the 6th rib

Question 14

How does blood flow through the heart (brief overview)?

Answer 14

-into right atrium from body
-moves into right ventricle
-pushed into pulmonary arteries where it becomes oxygenated
-travels back to heart through pulmonary veins
-enters the left atrium of the heart
-moves into the left ventricle and into the body tissues through the aorta

Question 15

Where are the four chambers of the heart located on an anterior view?

Answer 15

-Right atrium
-Right ventricle
-Left atrium
-Left ventricle

Question 16

What are the anterior landmarks of the heart?

Answer 16

-aortic valve
-pulmonary valve
-Erb’s point
-tricuspid valve
-mitral valve

Question 17

Where is the aortic valve (anterior landmark of the heart) located? Where should it be auscultated?

Answer 17

Located at the junction of the left ventricle and beginning of aorta
Auscultate: RIGHT 2nd intercostal space

Question 18

Where is the pulmonary valve (anterior landmark of the heart) located? Where should it be auscultated?

Answer 18

Located at the junction of the right ventricle as it enters the pulmonary trunk
Auscultate: LEFT 2nd intercostal space

Question 19

Where should Erb’s point (anterior landmark of the heart) be auscultated?

Answer 19

Auscultate: LEFT 3rd intercostal space
Nice generic one stop point to pick up any abnormal sounds in the heart

Question 20

Where is the tricuspid valve (anterior landmark of the heart) located? Where should it be auscultated?

Answer 20

Located between the right atrium and right ventricle
Auscultate: LEFT 4th/5th intercostal spaces at the left sternal border (where sternum meets rib) **right around where right ventricle is (problem from the tricuspid valve will be picked up from sounds in the right ventricle)

Question 21

Where is the mitral valve (anterior landmark of the heart) located? Where should it be auscultated?

Answer 21

Located between the left atrium and the left ventricle
Auscultate: LEFT 5th intercostal space along the midclavicular line (lined up with the middle of the left clavicle)
**right around where left ventricle is (problem from the mitral valve will be picked up from sounds in the left ventricle)

Question 22

What is the anterior median (midsternal) line of the thorax?

Answer 22

Reference vertical line that descends from mid sternum (divides body into right and left)

Question 23

What are the midclavicular lines (MCL) of the thorax?

Answer 23

Reference vertical line that descends from middle of each of the clavicles

Question 24

What is the posterior median (midspinal/midvertebral) line of the thorax?

Answer 24

Reference vertical line that descends through spinous processes of vertebrae (spine) and separates body into right and left

Question 25

What are the posterior scapular lines of the thorax?

Answer 25

Reference vertical line that descends through the inferior angles of the right and left scapula

Question 26

What is the anterior axillary line of the thorax?

Answer 26

Reference vertical line that descends through the anterior border of the armpit

Question 27

What is the mid axillary line of the thorax?

Answer 27

Reference vertical line that descends through the middle of the armpit (dividing armpit into right and left equal parts)

Question 28

What is the posterior axillary line of the thorax?

Answer 28

Reference vertical line that descends through the posterior border of the armpit

Question 29

What are the significant landmarks of the male breast?

Answer 29

Nipples

Question 30

Where are nipples located on the thorax in men?

Answer 30

4th intercostal spaces just lateral to midclavicular line

Question 31

What part of the heart is located just inferior/medial to the left nipple on a male thorax?

Answer 31

Apex of the heart (located in 5th intercostal space)
*can use the male nipple as a reference point for finding the 5th intercostal space/listen to the mitral valve/left ventricle

Question 32

What are the significant landmarks of the female breast?

Answer 32

-circular base (starts from mid-sternum and extends laterally)
-axillary tail (aka axillary process) *this is the part of the breast that extends to the mid-axillary line

Question 33

What are the two methods of clinical documentation of the female breast?

Answer 33

-quadrants
-“clock” positions

Used to document findings like cysts, tumors, etc.

Question 34

How would you describe the quadrant documentation method for the female breast?

Answer 34

Breast separated into 4 quadrants (vertical and horizontal lines across the middle of the breast form these quadrants)
Quadrants are:
-Upper inner/medial quadrant
-Lower inner/medial quadrant
-Upper outer/lateral quadrant
-Lower outer/lateral quadrant

Question 35

How would you describe the “clock” positions documentation method for the female breast?

Answer 35

Using a vertical and horizontal line through the middle of the breast, the numbers on a clock are used for reference of a position
-Top of vertical line: 12 o’clock
-Right end of horizontal line: 3 o’clock
-Bottom of vertical line: 6 o’clock
-Left end of horizontal line: 9 o’clock

Question 36

What is important to consider when using the “clock” position documentation method for the female breast?

Answer 36

Whether it is the left or right breast
For example,
3 o’clock on the right breast would be considered medial
BUT
3 o’clock on the left breast would be considered lateral

Question 37

75% of lymphatic vessels in the breast drain into which nodes?

Answer 37

Axillary (armpit) lymph nodes

Question 38

Where do the rest of the lymph vessels in the breast drain (the ones that don’t drain into the axillary nodes)?

Answer 38

Drain medially through the parasternal lymph nodes

Question 39

Why is it important to palpate the axillary region?

Answer 39

To assess for enlargement of lymph nodes (cancer cells may have drained from the breast tissue and into axillary lymph nodes)
-If not addressed, could enter the venous system and spread even further

Question 40

What is post-surgical lymphedema?

Answer 40

-Surgery may damage the lymph vessels in the axilla, or if lymph vessels here are removed due to pathology, drainage of lymph from the arm would be blocked/edema would result from a backup of the lymph drainage pathway