Thorax Flashcards
Identify on skeleton bony landmarks of the thoracic region including thoracic vertebrae, sternum, ribs.
C7 “Vertebra Prominens” = first palpable spinous process
T2 = Superior angle of the scapula
T3 = Root of the spine of the scapula
T7 = Inferior angle of scapula
T12 = Mid-point between the inferior angle of the scapula and top of iliac bone along the scapular line
L4 = highest point of the iliac crest
Ribs: 1-7=true, 8-10=false, 11,12=floating
Identify surface markings of bony landmarks –suprasternal notch, sternal angle, xiphisternum, costal
margins, and thoracic vertebral levels.
T2 – Superior angle of scapula
T2/3 - Jugular Notch
T3 – Medial end of scapula
T4/5 - Sternal angle / manubriosternal joint. 2nd costal cartilage is right next to this
T7 – Inferior angle of scapula
T5-8 - body of sternum
T8/9 – Xiphisternal joint
T9 – Xiphisternum
Describe and demonstrate the surface marking and palpation of the trachea at the suprasternal notch
- Palpation above the jugular notch
- Should be symmetrical, no deviation
Demonstrate how you would investigate symmetrical inflation of the lung and describe the anatomical
basis.
- Place hands around lower part of chest (R5/6) (as if squeezing together), with thumbs touching at the midline.
- Ask patient to take a big breath in and out and look at your thumbs – there should be equal expansion on both sides of the midline.
- Normal expansion is about 5cm
Observe and describe the breathing pattern and the breathing rate.
- Ask to take patient’s pulse. Look at chest. Want to see symmetrical rise.
- Normal rate – 12-20/min. Below = bradypnoea, above = tachypnoea
- Pattern – Regular, obstructive (prolonged expiration), Kussmaul’s (fast and deep), Cheyne-Stokes (Increasing in frequency and depth, to a peak, then decreasing in freq. and depth to a period of apnoea.
Demonstrate percussion of upper/lower/middle lobe(s) of right/left lungs.
- Hollow, drum-like sound over air-filled spaces (i.e. lung)
- Dull sound over sold organs (heart) or liquids
- Percuss the front as they lie 45°, percuss the back when they lean forward
- Ask the patient to cross their arms when listening to the back – this moves the scapula out of the way (protraction).
- Press middle finger into ICS, tap distal phalangeal joint (clavicle – tap directly).
- Compare right and left
Superior lobe
- Anterior: Clavicle (medial third), 2nd ICS MCL, 4th ICS MCL (LHS only)
- Posterior: 1st ICS medial sternal border (MSB), 3rd ICS MSB
Middle lobe
- Anterior: 4th ICS MCL RHS, 6th ICSL MAL RHS (Useful in F)
Inferior Lobe
- Anterior: 6th ICS MCL, 6th ICS MAL
- Posterior: 7th ICS Scapular line
Describe/ demonstrate where you would auscultate upper/middle/lower lobe(s) of right/left lungs
- All areas with diaphragm (except 1 and 2 – use the bell).
- Bronchial breathing – over trachea, manubrium and sternal angle (high pitched)
- Vesicular breathing – everywhere else
- Ask pt. to breathe through mouth
- Listen for equal L+R, S, M+L.
Superior lobe
- Anterior: Clavicle (medial third), 2nd ICS MCL, 4th ICS MCL (LHS only)
- Posterior: 1st ICS medial sternal border (MSB), 3rd ICS MSB
Middle lobe
- Anterior: 4th ICS MCL RHS, 6th ICSL MAL RHS (Useful in F)
Inferior Lobe
- Anterior: 6th ICS MCL, 6th ICS MAL
- Posterior: 7th ICS Scapular line
Listen for added sounds (wheeze, crackles, plural rub)
Describe & demonstrate the surface markings of upper, middle, lower lobe of right/left lungs.
Superior Lobe (RHS):
- Apex at 1inch above medial 3rd of clavicle
- Over sternoclavicular joint
- Down the right sternal border (RSB) to R4, follows R4 round to T3/4
- Lateral to spine to apex
Superior Lobe (LHS):
- Apex at 1inch above medial 3rd of clavicle
- Over sternoclavicular joint
- Down the right sternal border (RSB) to R6 (Deviation at R4-6 2-3cm)
- Round to T3/4
- Lateral to spine to apex
Middle Lobe (RHS):
- RSB R4
- Follows RSB to R6
- Follows R6 to MCL
- Up to R4 MAL
Inferior Lobe (RHS):
- R6 MCL to R4 MAL
- To T3/4
- Down lateral to spine to T10
- Round to R6 MCL
Inferior lobe (LHS)
- 6th rib MCL, 8th rib MAL, 10th rib posteriorly to spine
- Superior border of the inferior lobe follows 6th rib MCL to 4th rib MAL to 3/4th vertebra
Describe and demonstrate the surface markings of the oblique and horizontal fissures of right/left lung.
Oblique Fissure (Both): - R6 MCL to R4 MAL to spine of T3 posteriorly (usually follows the medial border of scapula when the arm is raised above the head)
Horizontal Fissure (RHS):
- RSB CC4, follows R4 to MAL to join oblique fissure
- Just above the nipple in males
Describe and demonstrate the surface marking of the inferior margin of parietal pleura of right/left lung.
- Apex at 1 inch above medial 3rd of clavicle
- Over sternoclavicular joint
- Down sternal border to xiphisternal joint - just right/left of anterior median line at centre of sternal angle, level of 4th CC and level of 6th CC
- R8 at MCL
- R10 at MAL
- R12/T12 at medial scapular border (lateral margin of erector spinae muscles)
- Transverse process of L1 vertebra to T1 transverse process
- (LHS, deviation 1cm from R4-6)
Describe and demonstrate the surface marking of the visceral pleura of right/left lung.
- Apex at 1 inch above medial 3rd of clavicle
- Over sternoclavicular joint
- Down sternal border to xiphisternal joint - just right/left of anterior median line at centre of sternal angle, level of 4th CC and level of 6th CC
- R6 at MCL
- R8 at MAL
- R10/T10 at medial scapular border
- Up lateral to spine to T1
- (Left lung, deviation 2-3cm from R4-6)
Describe and demonstrate the triangle of safety for insertion of a chest drain.
Why is one performed?
- Ant: Anterior axillary fold of pectoralis major
- Post: Posterior axillary fold of latissimus dorsi
- Inf.: 5th ICS at MAL.
- Sup: Below apex of axilla (R2)
- Placement – above superior border of inferior rib to avoid the intercostal nerve, pointing upwards and medially (Needle point 2nd, 3rd, 4th, 5th ICS in MAL)
- Why do one? – Pneumothorax, pleural effusion, haemothorax, post-op
- For apical pneumothoraces, 2nd ICS MCL used
Describe & demonstrate the surface marking of mediastinal pleura of right & left lung on the anterior
chest wall
- R sternoclavicular joint over RSB to R6 (becomes diaphragmatic pleura)
- Break at sternal angle for lung root
- L sternoclavicular joint over RSB to R6 (becomes diaphragmatic pleura)
- Indentation from R4-6 2-3cm
Demonstrate the surface marking of upper/right/inferior/left borders of the heart.
- Upper – CC3 1cm from RSB to 2.5cm left of LSB at CC2
- Right – Lat to RSB at CC3 to RSB 6CC (1cm form sternal border)
- Inferior – RSB CC6 to 5th ICS MCL
- Left – 2nd CC 2.5cm to LSB to 5th ICS at MCL
Demonstrate where you would auscultate for aortic/pulmonary/mitral/tricuspid valves using a
stethoscope.
Aortic – RSB 2nd ICS (located at 3rd ICS)
Pulmonary – LSB 2nd ICS (located at 3rd CC)
Tricuspid – LSB 5th ICS (located at 4th ICS)
Mitral – MCL 5th ICS (apex beat - actually located at 4th CC)
A place to meet at 22:55
