Thoracic Cage Consists Of:

- The sternum HISTORY OF PRESENT ILLNESS

- vertebrae
- the diaphragm (which forms the floor)
Anterior Thorax, Surface Landmarks Include:
- The suprasternal notch;
- The sternum (or breastbone), which has a
manubrium, body, and xiphoid process;
-The sternal angle (or angle of Louis), which is
continuous with the second rib;
- the costal angle, where the right and left costal
margins meet at the xiphoid process.
On The Posterior Thorax, Surface Landmarks
Include:
- The vertebra prominens;
- The spinous processes;
- The inferior border of the scapula, usually at the
seventh or eighth rib;
- the twelfth rib.
Explore The Following:
- whether the patient coughs or complains of
coughing,
- the onset and nature of the cough, sputum
characteristics,
- pattern and severity of the cough, associated
symptoms (e.g., hoarseness), and
- efforts to treat.
Document The Following Data:
- whether the patient has or complains of shortness
of breath,
- the onset of the problem,
- pattern and factors facilitating or relieving it, and -
associated symptoms (e.g., such as diaphoresis), and
- efforts to treat.
Complaints or signs of chest pain should be noted,
along with their onset and duration, associated
symptoms (e.g., fever), and any treatment efforts.

What Landmarks Should Be Used On The PAST MEDICAL HISTORY

Anterior Chest? Pertinent Data Include:
use the midsternal and midclavicular lines - past thoracic trauma or surgery,
- the use of oxygen,
What Landmarks Should Be Used Posterior - chronic pulmonary diseases,
Chest? - other systemic disorders (e.g., cancer),
use the vertebral and scapular lines - related respiratory tests,
- immunization against pneumonia, influenza
What Landmarks Should Be Used On The - the use of daily medications, both prescription and
Lateral Chest? nonprescription.
use the anterior axillary, posterior axillary, and
midaxillary lines FAMILY HISTORY
A Family History Of:
Apex of The Lung - tuberculosis,
(the highest point) lies 3 or 4 cm above the inner - cystic fibrosis,
third of the clavicles - emphysema,
- allergies,
The Base of Lung - smoking,
(lower border) rests on the diaphragm at about the - malignancy,
fifth intercostal space in the right midclavicular line - clotting disorders,
and at the sixth rib, the midclavicular line on the left -the risk of pulmonary embolism, bronchiectasis,
and bronchitis should be noted.
Lateral Landmarks
lung extends from the apex of the axilla to the PERSONAL AND SOCIAL HISTORY
seventh or eighth rib Work-Related Exposure To:
- irritants,
Posterior Landmarks - allergens,
C7 marks the apex, and T10 usually corresponds to - hazards
the base. On deep inspiration, the lungs expand their
lower border to the level of T12.
USE OF PROTECTIVE DEVICES SHOULD What Are You Inspecting For In Relation To
BE DOCUMENTED. Lungs?
Environmental factors in the home include: -chest landmarks.
- type of heating, - skin, nails, and lips.
- air conditioning, - Smell for odors of the breath.
- and humidification. - Count respiration rate for 60 seconds.
- Note respiratory pattern and movements.
Other relevant data include: - Inspect chest wall movement for symmetry.
- drug and alcohol consumption;
- tobacco use;
- exercise tolerance; What should you be inspecting in regards to
- travel history; respiration?
- potential exposure to respiratory infections, such Rate - 12-20/min adult
as influenza, or tuberculosis; Rhythm - regular, irregular
- nutritional status Depth - shallow, deep
- weight loss or obesity Effort - effortless, quiet

Hobbies: Symmetry
- owning pigeons, parrots, or other animals, Accessory muscle use Nasal flaring
- woodworking,
- welding and exercise tolerance: diminished ability Inspect Shape of Thorax
to perform up to expectations. Normal Anteroposterior Ratio = 1 : 2 (Barrel chest
1:1 r/t COPD)
Self-Care Behaviors Anterior Structural Deformities
When was your last TB skin test, chest x-ray study, Posterior Structural Deformities
pneumonia or influenza immunization?
Palpate the Chest
Examine the posterior thorax and lungs while Thoracic expansion - symmetric movement
the patient is sitting Tenderness
Examine the anterior thorax and lungs with the Crepitus
patient supine
Compare one side of the thorax and lungs with Tactile fremitus - a palpable vibration
the other "Say 99"

WHAT ORDER SHOULD THE ASSESSMENT Palpate Anterior and Posterior Chest Bones And
BE PERFORMED IN? Muscles For
inspect, palpate, percuss, and auscultate pulsations
pain
INSPECT bulges
The Posterior And Anterior Chest. movement
Note The: depression
- shape, crepitation
-configuration, and positions.
-symmetry of the thoracic cage,
- anteroposterior ratio, Palpate tactile fremitus at bifurcation of bronchi by
-placement of the scapulae, using palmar surfaces of fingers or ulnar surfaces of
-angle of the ribs, and the hand
-development of the neck and trapezius muscles. How do you assess the trachea?
inspection is what type of data Move index fingers in suprasternal notch and inner
objective borders of sternocleidomastoids

Why do we percuss chest?

To determine size, location, organ boundaries, assess the condition of the surrounding lungs and
density pleural space
and to map out the lower lung border and measure
diaphragmatic excursion. Normal vesicular breath sounds:
soft and low pitched; usually heard over most of
Where do we percuss? both lungs
anterior, posterior, and lateral chest at 4- to 5-cm (peripheral lung fields)
intervals, moving from superior to inferior and
medial to lateral using one side as a control. Normal Bronchial breath sounds
Perform from side to side to assess for asymmetry louder and higher in pitch; usually heard over the
manubrium (Trachea, larynx)
How do we percuss?
-Strike using the tip of your tapping finger
-Use the lightest percussion that produces a clear Normal Bronchovesicular breath sounds
note intermediate intensity and pitch (medium pitch);
-Percussion helps establish whether the underlying usually heard over the 1st and 2nd interspaces
tissues -(5-7 cm deep) are air-filled, fluid-filled, or (Upper sternum, scapula)
solid
Examples of adventitous (added) sounds
What sound is normal in lung fields? Crackles (Rales)
resonance (hyperresonance in child's lung) Fine
Course (Rhonchi)
When do we hear hyperressonance? Atelectatic crackles not pathologic
emphysema Wheezes
pneumothorax Pleural Friction Rubs
child's lung Stridor (blocked airway)

When do we hear dull sounds during percussion? If you have abnormal finding in breath sounds,
-pneumonia auscultate for
- pleural effusion voice sounds
- atelectasis Voice sounds
- tumor Not done routinely
- liver Normally hear soft, muffled, indistinct sounds

When do we hear flat sound while percussing? Bronchophony voice sounds

over bones say "99"

Auscultation Egophony voice sounds

Auscultation of the lungs is the most important "e" sounds like "a"
examination technique for assessing air flow
through the tracheobronchial tree Whispered Pectoriloquy voice sounds
Use the pattern suggested for percussion, moving Whisper "1, 2, 3"
from one side to the other and comparing symmetric
areas of the lungs Examine the anterior chest by:
Listen to at least one full breath in each location; proceed in an orderly fashion: inspect, palpate,
have pt breathe deeply through an open mouth. percuss, and auscultate
During anterior chest percussion, where will you
Which side of the stethescope do you use to hear dullness from heart?
ausculatate lungs? to the left of the sternum from the 3rd to 5th rib
Diaghram interspaces

auscultation and percussion together help:

During anterior chest examination, is
supraclavicular retraction often present?
Yes!
Normal Findings in an adult during thoraxic
inspection:
- Anteroposterior diameter is half the size of
transverse diameter.
- Respiratory rate is 12 to 20/minute.
- Ratio of respirations to heartbeat is 1:4.
- Chest expansion is equal bilaterally.
- Bronchial, bronchovesicular, and vesicular breath
sounds heard on auscultation
Typical variations in an adult during thoraxic
inspection:
- Decreased tactile or vocal fremitus is associated
with emphysema.
- Hyperresonance indicates hyperinflation of lungs.
- Dullness indicates lung consolidation. Work-
related exposure to irritants and allergens and use of
protective devices should be explored.
Findings Associated with Disorders in adults during
a thoraxic exam:
- Shallow respirations are associated with injured
rib, pleurisy, liver enlargement, or abdominal
ascites. Slow respirations may mean neurologic or
electrolyte problems, infection, or pleurisy.
- Barrel chest found with obstructive pulmonary
disease and is associated with chronic disease
- Asymmetric, unequal expansion of the lungs may
be caused by extrapleural air, fluid, or mass.
- Expiratory bulging may indicate enlarged heart,
tumor, or aneurysm.
Chest asymmetry suggests pneumothorax.
Normal Findings in infants and children during
thoraxic inspection:
- Respirations are 40 to 60/min.
Xiphoid process is prominent with sharp tip
Typical variations in infants and children during
thoraxic inspection:
- Hyperresonance is common in children
- Minimal pectus carinatum and pectus excavatum
may be present.
- Rales and rhonchi are common.
- Transient tachypnea is associated with cesarean
birth.
- Preterm infants may have irregular respiratory rate
or apneic periods.
Findings Associated with Disorders in infants and
children during a thoraxic exam:
- Pursed lips indicate increased expiratory effort.
- Flared nares suggest air hunger. Chest roundness
(increased anteroposterior diameter) after 2 years of
age indicates chronic obstruction.
- Gastrointestinal gurgle in chest indicates
diaphragmatic hernia.
- Unilateral retractions may be caused by foreign
body.
- Dry, hoarse, barking cough suggests croup.
Inspiratory whoop with coughing is associated with
pertussis. Nasal flaring and intercostal, sternal, or
suprasternal retractions indicate respiratory distress
- Stridor indicates high respiratory obstruction in
infants and children
Normal Findings in older adults during thoraxic
inspection:
- With aging, there is loss of muscle strength of
thorax and diaphragm, resulting in decreased lung
resiliency.
- Alveoli are less elastic and more fibrous.
Typical variations in older adults during thoraxic
inspection:
- Older adults have less chest expansion; larger
anteroposterior diameter; and marked, bony
prominences.
- Aging is associated with kyphosis, use of
accessory muscles, and hyperresonance.
Findings Associated with Disorders in older adults
during a thoraxic exam: Heart failure
- Cheyne-Stokes respiration (periodic respiration.. pump failure w/ incr. blood in pulmonary, increased
periods of apnea mixed with shallow breathing) RR, dyspnea on exertion, orthopnea, pallor, moist &
implies serious condition. clammy skin, resonance, heart sounds include S3,
and crackle at lung base.
- Chest pain should be noted along with onset,
duration, and associated symptoms of diaphoresis or
shortness of breath.
What is the leading cause of preventable death in
the United States
smoking

Promote smoking cessation. The concepts of

exposure to secondhand smoke, also known as
environmental tobacco smoke (ETS) should be
discussed. Terms such as sidestream smoke (smoke
from the burning end of a cigarette, pipe or cigar)
and mainstream smoke (the smoke exhaled from the
lungs of the individual who is smoking) should be
explained to the patient.
The five A's with smoking are:
- Ask about smoking at each visit
- Advise patients regularly to stop smoking using a
clear, personalized message
- Assess patient readiness to quit
- Assist patients to set stop dates and provide
educational materials for self-help
- Arrange for follow-up visits to monitor and
support patient progress

Atelectasis
collapsed or shrunken section of alveoli or entire
lung. R/t 1) airway obstruction, 2) compression on
lung, or 3) lack of suractant. AEB: lag on one side
for chest expansion, dull percussion, decreased or
absent breath sounds.

Lobar pneumonia
Infection in lung, alveolar fill with debris, fluid,
bacteria and blodd cells leading to hypoxemia.
AEB: incr. RR, lag unilateral on expansion, dull
percussion, voice sounds increased clarity

Asthma
allergic hypersensitivity to inhaled allergens
characterized by bronchospasm and inflamation.
AEB: increased RR, dyspnea, wheezing, labored
breathing, decreased tactile fermitus, tachycardia,
resonance upon percussion, hear diminished breath
sounds, and bilateral wheezing.