Thorax 3: Flashcards
What are the atypical ribs of the thoracic cage?
1st rib (Flat rib)
11th rib (Floating)
12th rib (Floating)
The head of the first rib articultes with? What does the costal cartillage of the first rib joint together with to form?
T1
Costal cartillage joins with manubrium to form a primary cartilagenous joint
What ribs are considered true, false and floating ribs?
True = 1-7 (connect directly to sternum)
False = 8-10 (do not directly connect to sternum)
Floating = 11-12 (No connection to sternum)
Which ribs show pump handle movement?
Which ribs show bucket handle moevement?
Upper ribs: Pump handle movement
Lower ribs: Bucket handle movement
The jugular notch is at which vertebral level
T2/T3
The sternal angle (aka manubriosternal joint) is located at what vertebral levels?
T4/T5
The xiphisternal joint is located at what vertebral level?
T8/T9
Palpate the following spinous proccesses:
C7
T2
T3
T7
T12
L4
N.B. You can tell if its C7 by telling patient to put head back. The first palpable process is c7
Surface landmark the pleura of the right lung on the anterior chest wall
(A) Apex of the pleura (in the root of neck, above medial 1/3 of the clavicle)
(B) Just over the sternoclavicular joint
(C) Just right of AML at centre of sternal angle – level 2nd CC
(D) Just right of AML at level of 4th CC
(E) Just right of AML at level of 6th CC (xiphoid process)
(F) MCL at the level of 8th rib (just above costal margin)
(G) MAL at the level of 10th rib (lowest point of costal margin)
Surface landmark the pleura of the right lung on the posterior chest wall
(G) MAL at the level of 10th rib (lowest point of costal margin)
(H) Scapular line (medial border of scapula) crosses the 12th rib.
(I) Transverse process of L1 vertebra (subcostal pleura below 12th rib)
(J) Transverse process T1 vertebra (first palpate spine of T1)
Surface landamrk the entirety of the right pleura of the lung
(A) Apex of the pleura (in the root of neck, above medial 1/3 of the clavicle)
(B) Just over the sternoclavicular joint
(C) Just right of AML at centre of sternal angle – level 2nd CC
(D) Just right of AML at level of 4th CC
(E) Just right of AML at level of 6th CC (xiphoid process)
(F) MCL at the level of 8th rib (just above costal margin)
(G) MAL at the level of 10th rib (lowest point of costal margin)
(H) Scapular line (medial border of scapula) crosses the 12th rib.
(I) Transverse process of L1 vertebra (subcostal pleura below 12th rib)
(J) Transverse process T1 vertebra (first palpate spine of T1)
Connect all points (A) to (J).
How does surface marking the left lung differ to the right?
Be wary of cardiac notch
Draw a notch between 4th costal cartiallage and 6th rib
Surface landmark the left LUNG in its entirety
Draw the oblique fissure of the right lung
Oblique fissure begins at junction between 6th rib and mid-clavicular line in anterior side
Runs along to the posterior region where it ends at the T3 level
List the step by step strcutured approach of a respiratory examination
1) Position (correct positioning of the patient and your position)
2) Inspection (observing with your eyes using visual sense)
3) Palpation (feeling with your hands using touch sense)
4) Percussion (tapping on the body parts to elicit sounds)
5) Auscultation (listening to sounds using a stethoscope using your hearing sense)
6) Assessment of function (putting into action)
For most of the respiratory system examination, it is important to have the patient lying in what matter?
Supine position with upper body elevated 35-45 degrees
In a respiratory examination, what 7 things must be inspected for from the end of the bed?
In a respiratory examination, what 6 things must be inspected for on the hands?
Look for peripheral cyanosis on hands
Look for tar staining on palms (smoking)
Finger clubbing
Temperature of arms
Assess for fine tremors (indicates B2 agonist/salbutamol use)
Assess for asterixis (CO2 retention)
Assess the respiratory rate and state the normal range
Tell patient that you would like to feel for their pulse
Pretending to feel for pulse, assess the respiratory rate by counting the amount of breaths per minute.
Normal range is 12-20 breaths per minute
Assess the JVP (Jugular venous pressure). What does a raised JVP indicate?
Ask patient to turn their head to the left
The jugular vein should be located between the sternocleomastoid heads.
Raised JVP indicates Cor pulmonale (aka Right-sided heart failure)
Inspect the face and describe what you are looking for.
First ask patient to look straight ahead for you and check for central cyanosis (indicates hypoxia)
Ask to pull down on the lower eyelid and check for conjunctival pallor (pale conjunctiva indicates anaemia)
Inspect the mouth and descrieb what you are looking for
Ask patient to open mouth (look for angular stomatitis [redness at angle of lips]
Ask patient to lift toungue towards roof of mouth (assess for central cynaosis)
Inspect the chest and describe what you are looking for.
Look for scars
Chest wall deformities
Then ask patient to lift their arm for you (do for both sides) and inspect for scars (lateral thoracotomy)
Assess the tracheal position
Put two fingers on opposite sides of sternal head of sternocleomastoid muscle and use middle finger. Place it on the trachea and dragn finger dowm trachea using the other two fingers as reference/
Alternative: Place middle finger in jugular notch. With the two fingers adjacent, place them on the opposite sides of the trachea moving downwards and assesing for deviation.
What are 2 causes for tracheal deviation away from the lesion?
What are 2 causes for tracheal deviation towards the lesion?
Away: Tension pneumothorax, Large pleural eflusions
Towards: lobar collapse, pneumonectomy
Assess for the cricosternal distance. What is a normal finding?
Put as many fingers as you can between the sternal notch and the cricoid cartillage
Normal finding is 3-4 fingers
(Less fingers can indicate COPD or other conditions which result in hyperinflation)
What is an abnormal finding when measuring cricosternal distance and what does this suggest?
Less than 3 fingers between jugular notch and the cricoid cartillage.
Suggests hyperinflation caused by COPD or asthma for example
Palpate the apex beat
Beat can be felt at mid-clavicular line at the 5th intercostal space
List 3 causes for a misplaced apex beat
Right ventricular hypertrophy
Large pleural effusion
Tension pneumothorax
Assess chest wall expansion
Place your hands on the patient’s chest, inferior to the nipples.
Wrap your fingers around either side of the chest.
Bring your thumbs together in the midline, so that they touch.
Ask the patient to take a deep breath in.
Observe the movement of your thumbs (in healthy individuals they should move symmetrically upwards/outwards during inspiration and symmetrically downwards/inwards during expiration
What does symmetrical reduced chest expansion suggest?
Pulmonary fibrosis
Give 3 examples of causes of asymetrical reduced chest expansion.
pneumothorax
pneumonia
pleural effusion
Percuss the anterior chest wall
Suggested areas:
Apex (supraclavicular)
Infraclavicular
2nd intercostal space (nearish mid-clavicular line)
6th intercostal space [Inferior lobe]
Axilla
What does consolidation, lobar collapse and a tumor sound like upon percussion?
Dull
A patient with a pneumothorax will have which type of sound upon percussion?
Hyperesonance
How would you assess tactile vocal fremitus?
Using the ulnar (pinky finger) side of the hand, ask patient to say 99 and assess major regions of the anterior and posterior chest wall and compare the vibration.
Increased vibration in a tactile vocal fremitus assesment can suggest?
Increased tissue density (e.g. consolidation, tumour, lobar collapse).
Reduced vibration in a tactile vocal fremitus assesment can suggest?
Decreased vibration over an area suggests the presence of fluid or air outside of the lung (e.g. pleural effusion, pneumothorax).
Normal breathing sound is described as? Describe what normal breathing sounds like
Vesicular breathing
Soft, low pitched, and rustling in quality
Inspiratory phase lasts longer than the expiratory phase
Intensity of inspiration is greater than that of expiration
Inspiration is higher pitch than expiration
No pause between inspiration and expiration
How does bronchial breathing differ from vesicular breathing? What does detection of bronchial breathing in non bronchial areas suggest?
Harsh-sounding (similar to auscultating over the trachea)
inspiration and expiration are equal and there is a pause between.
This type of breath sound is associated with consolidation.
Reduced breath sounds (quiet) suggests?
Reduced air entry (do not say its reduced air sounds in notes it is known as reduced breath sounds) e.g. pneumothorax, pleural effusion
