Thorax CAS 1

Question 1

What are important surface landmarks of anterior chest?

Answer 1

Along midline: Suprasternal notch, sternal angle, anterior median line
Midclavicular lines
Axillary fossa, Anterior axillary line, Midaxillary line, Posterior axillary line

Question 2

What are important surface landmarks of posterior chest?

Answer 2

Spinous process of C7, Scapular lines, Posterior median line

Question 3

Describe surface landmarks of the anterior chest along the midline

Answer 3

Jugular notch marks level of T2/3
Clavicle and anterior axillary fold along same level 
Manubrium 
Sternal angle and manubriosternal joint on level of T4/5
Rib
Intermammary cleft found in females 
Body of sternum located just below intermammary cleft in females and just above point of infrasternal angle in males 
Xiphisternal joint marks level of T8/9
Epigastric fossa 
Subcostal angle 
Costal margin
Midclavicular line

Question 4

Describe surface landmarks of the posterior chest along the median line

Answer 4

Position of external occipital protruberance
C2 vertebral spinous process
C7 vertebral spinous process
T1 vertebral spinous process
T3 vertebral spinous process on level with root of spine of scapula
T7 vertebral spinous process on level with inferior angle of scapula
T12 vertebral spinous process
L4 vertebral spinous process on level with highest point of iliac crest
S2 vertebral spinous process on level with iliac crest and sacral dimple
Tip of coccyx

Question 5

Describe the heart’s location

Answer 5

2/3 lies on the left of the midsternal line while 1/3 lies to the right. The heart sits within the pericardial sac which is attached to the diaphragm.

Question 6

What are the 4 points of the heart?

Answer 6

2nd CC (costal cartilage) is 2.5cm from sternal border on left
3rd CC is 1cm from sternal border on right
5th ICS (intercostal space) to apex beat at MC line is 9cm from sternal border on left
6th CC is 1cm from sternal border on right

Question 7

What is an apex beat?

Answer 7

The apex beat is a pulsation (either visible or palpable or both) caused by the apex of the left ventricle of the heart when it is forced against the anterior chest wall during contraction. The anatomical apex of the heart is not necessarily at the point where you feel the apex beat. By definition, the most lateral and inferior point at which the palpating fingers raise with each systole defines the position of the apex beat.

Question 8

How can apex beat be palpated?

Answer 8

1) Your colleague (or patient) should lie on a couch with head and back raised at 45 degrees.
2) You should approach and stand facing your colleague from their right side.
3) You should use your palm and 4 fingers of your right hand to palpate. You should align your fingers along the left 4th, 5th and 6th intercostal spaces.
4) You should start palpation from the left lateral chest wall (near the mid-axillary line), and move to the anterior chest wall (towards the midclavicular line).
5) If you find the apex beat difficult to palpate in your colleague, a brisk “jogging on the spot” by your colleague (for 1 minute) may increase the heart rate and strength of the heart beat that enables easier palpation.
6) In females, the examiner’s hand should be laid beneath the breast along its lower border (a mitral valvotomy scar could be missed if the apex beat is not visualised).

Question 9

Where is the apex beat usually found?

Answer 9

The apex beat in a healthy adult is usually found in the left 5th intercostal space around the midclavicular line. In children, it is slightly higher on the 5th rib.

Question 10

What can a shift in the apex beat indicate?

Answer 10

A shift in the apex beat laterally or inferiorly or both normally indicates an enlargement (cardiomegaly) of the heart. Occasionally, the shift of the apex beat is due to chest wall deformity, mediastinal shift or underlying pleural and lung disease.

Question 11

What are types of abnormal apex beat?

Answer 11

1. Heave - Since the apex beat is a result of the left ventricle beating, hypertrophy of the left ventricle produces a forceful beat called a ‘heave’ and may extend outwards towards the axilla.
2. Thrill - A hyperkinetic and more sustained apex beat called a ‘thrill,’ is more characteristic of volume overload, and may occur in heart failure, and mitral and aortic regurgitation.
3. Dextrocardia - apex beat will be palpable on the right side of the sternum.

Question 12

When can an apex beat not be palpable?

Answer 12

In patients with thick chest wall, emphysema, pericardial effusion and shock.

Question 13

What are the four elements of a physical examination?

Answer 13

1. Inspection
2. Palpation
3. Percussion
4. Auscultation

Question 14

Where are the heart valves located and listened to from?

Answer 14

Mitral - left 5th intercostal space at the midclavicular line (= apex beat area).

Tricuspid - left 5th intercostal space near the sternum.

Pulmonary - left 2nd (or 3rd) intercostal space near the sternum.

Aortic - right 2nd intercostal space near the sternum.

Question 15

Where are the 4 heart valves found?

Answer 15

The four heart valves are embedded in the “fibrous skeleton” of the heart in the atrioventricular plane. All valves are located behind the sternum on a line running from the medial end of the left 3rd costal cartilage (CC) to the medial end of the right 4th intercostal space (ICS).

Question 16

Is the area best for auscultation the same as the position of the valve?

Answer 16

The areas best for auscultation do not correlate with the anatomical location of the valves. The sound produced by a given valve is carried by the blood stream along the direction of flow via the valve. Placing the stethoscope superficial to the blood filled space downstream of a given valve may allow the sound of that valve (including abnormal sounds) to be distinguished clearly from the sounds of other valves.

Question 17

What does palpation of arterial pulse evaluate?

Answer 17

1. Pulse rate – usually assessed by palpating right radial pulse and expressed in beats per minute.
2. Rhythm - usually assessed by palpating right radial pulse. The rhythm can be regular or irregular. Irregular rhythm is usually due to cardiac problems such as atrial fibrillation or ectopic beats.
3. Character and volume- usually assessed by palpating the right carotid artery pulse which is closest to the heart than the radial pulse.
4. Symmetry – of radial, brachial, femoral, popliteal, and pedal pulses can be assessed by comparing pulses on both sides.
5. Radio-femoral delays between major arteries might observed and are abnormal.

Question 18

Where can arterial pulses in upper limb be found?

Answer 18

1. Axillary artery - medial side of humerus (lateral wall of the axilla), posterior to the tendon of the short head of biceps.
2. Brachial artery (in the middle of the arm) - middle third of the humerus, in the medial bicipital groove between medial borders of biceps muscle and brachialis muscle.
3. Brachial artery (cubital fossa) - medial side of the tendon of biceps muscle in the cubital fossa. It is easier to palpate the pulse when the elbow is fully extended.
4. Radial artery - at the wrist over the anterior surface of the distal end of radius just lateral to the tendon of flexor carpi radialis muscle. The radial artery lies superficial and easily accessible. It is the most commonly used artery to measure patient’s pulse rate and rhythm.
5. Ulnar artery - at the wrist over the distal end of the forearm lateral to the tendon of flexor carpi ulnaris muscle.

Question 19

Where can arterial pulses in the head be found?

Answer 19

1. Common carotid artery - in the neck, between the lateral side of thyroid cartilage and medial border of sternocleidomastoid muscle. This is the strongest pulse of all. The carotid pulse is ideal for the assessment of the amplitude, shape and volume of the pulse that are important in the diagnosis of underlying heart disease.
2. Superficial temporal artery - in front of the tragus of the ear. This vessel is a terminal branch of the external carotid artery.
3. Subclavian artery - palpated in the supraclavicular fossa region, at the angle between clavicle and sternocleidomastoid muscle. At this site you can compress and occlude the artery completely against the upper surface of the first rib.

Question 20

What blood vessel courses can be traced along head?

Answer 20

The carotid artery runs in between a line from the earlobe to the sternoclavicular joint. While it initially starts as the common carotid, at the level of the mandible it branches to give rise to the external and internal carotid arteries where internal continues to the earlobe. Running alongside it is the internal jugular vein. At the level of the sternoclavicular joint, the superior vena cava has already branched to give rise to the right brachiocephalic trunk and the right subclavian vein is formed here. The left brachicephalic trunk also arises at this level.

Question 21

What is the clinical significance of the internal jugular vein?

Answer 21

The IJV is accessible for cannulation in the region of the apex of the triangle formed by the clavicular and sternal heads of the sternocleidomastoid muscle with the medial end of the clavicle. Here the vein is subcutaneous. The right IJV is usually preferred because it is larger and straighter.

Question 22

What is the most common site for venepuncture?

Answer 22

The cubital fossa where the veins are usually prominent and easily accessible.

Question 23

How can the superficial veins of the arms be identified?

Answer 23

Apply pressure around the middle of the arm of your colleague by encircling it with your hands while. Ask your colleague to pump the hand by opening and closing their fist. It will cause venous congestion and distention of the veins distal to the compression. In the cubital fossa region identify the median cubital vein which often connects the cephalic and basilic veins. At the dorsum of the hand the dorsal venous arch is visible. The basilic and cephalic veins of the forearm originate from the dorsal venous arch.