thorax 2 cas

Question 1

Surface Marking the Right parietal pleura: where is point A

Answer 1

The apex of the pleura (in the root of the neck above the medial 1/3 of the clavicle)

Question 2

B

Answer 2

Just over the sternoclavicular joint

Question 3

c

Answer 3

Just right of AML at centre of sternal angle–level 2nd costal cartilage

Question 4

d

Answer 4

Just right of AML at level of 4th costal cartilage

Question 5

e

Answer 5

Just right of AML at level of 6th CC (xiphoid process)

Question 6

f

Answer 6

) MCL at the level of 8th rib (just above costal margin)

Question 7

G

Answer 7

MAL at the level of 10th rib (lowest point of costal margin)

Question 8

h

Answer 8

Where the scapular line(lateral margin of erector spinae muscles) crosses the 12th rib. basically along the same ling as g

Question 9

I

Answer 9

Transverse process of L1 vertebra (subcostal pleura below 12th rib)

Question 10

j

Answer 10

Transverse process T1 vertebra (first palpate spine of T1)

Question 11

Surface Marking the lung outline

You will draw the lung outline as they lie in mid- inspiration.

Answer 11

a to e is the same

Question 12

how about f to i

Answer 12

follow two ribs above the pleural reflection around the chest wall.

Question 13

f

Answer 13

MCL at 6th rib (anteriorly)

Question 14

g

Answer 14

MAL at 8th rib (laterally)

Question 15

h

Answer 15

Scapular line at 10th rib (posteriorly)

Question 16

i

Answer 16

T12 level (posteriorly)

Question 17

how does the left and right lung differ

Answer 17

The outline for the left lung is same as for the right lung except for the mediastinal reflection below the 4th costal cartilage

2) Below the 4th costal cartilage, the cardiac notch deviates by 2-3 cm lateral at the level of 5th costal cartilage.
3) The lower border of the left lung follows the same course as the right lung.

Question 18

Oblique fissure for the right and left lung

Mark two points (OF1 and OF2)

Answer 18

OF1- 3rd thoracic fissure
OF2 Anteriorly at the lower border of the lung at the junction of the 6th costal cartilage and MCL.
Connect these two points by a smooth curved line running around the lateral thoracic wall. This line represents the oblique fissure.

Alternative method for drawing the oblique fissure: The oblique fissure closely follows the medial border of the scapula when the arm is raised above the head of the subject. Extrapolate this line anteriorly to meet the lower border of the lung.

Question 19

Horizontal (transverse) fissure of the right lung

Answer 19

To mark the horizontal fissure your will palpate the 4th costal cartilage on the right side and draw a line along the 4th costal cartilage and the 4th rib laterally to meet the oblique fissure in the midaxillary line. This marks the horizontal fissure between the upper and middle lobes of the right lung. It passes just above the nipple in the male. (Please note that the left lung does not have a middle lobe or a horizontal fissure).

Question 20

Assessment of the position of the Trachea

Answer 20

The assessment of the position of the trachea in the neck and at the suprasternal notch is part of routine clinical examination of the chest. This examination is slightly uncomfortable for the patient. Therefore you should be gentle when you palpate. You will follow the following steps when examining.

Question 21

Assessment of Chest Expansion§

Answer 21

You will stand facing the subject and place your hands firmly on the subject’s anterior chest wall (just below 5th or 6th ribs) with fingers extended around the sides of the chest. The thumbs should just meet in the anterior midline (mid-sternal line), resting lightly on the chest wall, to allow its movement during respiration. In female subjects,the examiner’s hands lie beneath the breasts.

You will ask the patient to take a deep breath and observe how far the tips of your thumbs move apart. In a normal healthy subject, it will move apart by at least 5 cm.

Repeat this examination on the posterior chest wall with thumbs meeting in the posterior midline at the level of 10th thoracic vertebra (T10). You will look for any asymmetry between right and left sides.

Question 22

Percussion of the Chest

where is it if posterior

Answer 22

Percussion is best performed while the subject sits on the edge of the couch.

Question 23

Anterior chest wall

Answer 23

Percussion is best performed clinically with the patient sitting on the couch at 45 degrees.

Question 24

percussion

Answer 24

Place your left hand over the subject’s chest wall with the fingers slightly separated.

2) Align the middle finger (this is your probing finger) of your left hand along an intercostal space with the middle phalanx pressing firmly on the chest wall.
3) Use the pad of the middle finger of your right hand and strike sharply on the middle phalanx of the probing finger of the left hand.
4) Hold the percussing finger (right hand middle finger) in a semi flexed position when you strike the middle phalanx of the left hand middle finger. The striking motion must come from the wrist joint, and not from your forearm.

Question 25

where for the anterior chest percussions

Answer 25

apex (on the shoulder line)
infrascapular (inline with mid shoulder)
2 and 6 intercostal spaces (above n and below pec

Question 26

where for posterior chest percussions

Answer 26

both sides of trapezuis - just below shoulder line
level spine of scapula ( in line with bottom arm)
10/11 rib (inline with n)

Question 27

when may you hear Hyper-resonant/high pitch

Answer 27

Hollow spaces such as pneumothorax or hollow bowels, or in patients with COPD you may hear hyper-resonant (high) note

Question 28

Hypo-resonant / flat or dull

Answer 28

Fluid filled such as pleural effusion you will hear a hypo-resonant (low

Question 29

when do you hear Bronchial sounds

Answer 29

These high pitch notes are normally heard over trachea (neck), suprasternal notch, manubrium, sternal angle, and sternoclavicular joints. In these areas,the airways are not surrounded by alveolar tissue, and therefore, the air turbulence in them is heard without any filtering.

Question 30

Vesicular sounds

Answer 30

These low pitch notes will be present all over the rest of the chest area where normal lung tissue is present. The lung tissue filters the sounds of air turbulence, which results in the low pitch vesicular sound.

Question 31

lung sound

Answer 31

Your colleague (patient) will lie on a couch with head and back raised (at 45 degrees). Anterior chest wall will be examine in this position. For the posterior chest wall, it is necessary to sit up at the edge of the couch.

2) You will use the diaphragm of the stethoscope to examine most of the areas of the chest except the area just above the clavicle where apices of the lungs are present, you will use the bell of the stethoscope.
3) Bronchial breathing: You will listen over the trachea, suprasternal notch, manubrium and sternal angle for bronchial breath sounds.
4) In females, you must not auscultate over the breast tissue. The only place you can access the middle lobe of the (right) lung is just below the right axilla. The lower lobes, on the anterior chest wall in females, can be accessed just below the base of the breast (at the level of the 6th rib).

You will compare each side of the chest with the other, both anteriorly and posteriorly.

6) If the breath sounds are inaudible, you will ask the patient to take deep breaths in and out through the open mouth.

Question 32

where to listen anteriorly

Answer 32

above clavicle using bell side apex
about 10cm above n superior. right
on line with n middle
diagnnoly down from n - under arm inferior

Question 33

posterior

Answer 33

above clavicle type part apex
middle of shoulder superior left
middle of tricep - inferior

place hands at those points like a high 10
get them to say 99 everytime they feel your hand

Question 34

You will draw the four borders of the safe triangle on your colleague as follows:

Answer 34

Posterior- Latissimus dorsi - posterior axillary fold
Anterior- Pectoralis major - anterior axillary fold
Inferior- 5th intercostal space at mid-axillary line
Superior- below apex of axilla

Question 35

where is the safe triangle

Answer 35

mid axillary

Question 36

where does the latissimus dorsi

Answer 36

comes up to mid axill in line with n