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Lecture Notes

Assessing the Thorax and Lungs


  1. purposes
    1. to determine changes in the internal environment of the body
    2. to yield valuable information on general health status
    3. to provide information needed to identify specific systemic diseases
    4. to determine the health status of the organs and sructures of the respiratory system
  2. stucture and function
    1. function
      1. the organs and structures of the respiratory system
    2. structure
      1. thoracic cage
        1. bony structure with a conical shape
        2. narrower at the top
        3. composed of:
          1. the sternum
          2. 12 pairs of ribs
            1. first seven ribs attach directly to the sternum via their costal cartilages
            2. ribs 8, 9, and 10 attach to the costal cartilage above
            3. ribs 11 and 12 are "floating" with free palpable tips
          3. 12 thoracic vertebrae
      2. anterior thoracic landmarks
        1. suprasternal notch
          1. hollow U-shaped depression just above the sternum, in between the clavicles
        2. sternum
          1. "breastbone"
          2. composed of:
            1. the manubrium
            2. the body
            3. the xiphoid process
        3. manubriosternal angle; "angle of Louis"
          1. articulation of the manubrium with the second rib
        4. costal angle
          1. angle where the right and left costal margins meet at the xyphoid process
          2. usuallly 90 degrees or less
      3. posterior thoracic landmarks
        1. vertebra prominens
          1. the most prominent bony spur protruding at the base of the neck when the head and neck are flexed
        2. spinous processes
          1. knobs on the back of the vertebrae
        3. inferior border of the scapula
          1. bottom of the scapula
        4. twelfth rib
      4. reference lines
        1. anterior chest
          1. midsternal line
            1. line drawn through the middle of the sternum
          2. midclavicular line
            1. bisects the center of each clavicle at a point halfway between the palpated sternoclavicular and acromioclavicular joints
        2. posterior chest
          1. vertebral (midspinal) line
            1. line drawn through the middle of the vertebral (spinal) column
          2. scapular line
            1. extends through the inferior angle of the scapula when the arms are at the sides of the body
          3. anterior axillary line
            1. extends down from the anterior axillary fold where the pectoralis major muscle inserts
          4. midaxillary line
            1. runs down from the apex of the axilla and lies between and parallel to the anterior and posterior axillary lines
          5. posterior axillary line
            1. continues down from the posterior axillary fold where the latissimus dorsi muscle inserts
      5. lobes of the lungs
        1. left
          1. composed of two lobes
            1. superior
            2. inferior
            3. left lung is narrower than the right to accomodate the heart
          2. one left mainstem bronchus
          3. two secondary (lobar) bronchi
            1. one into each lobe of the left lung
          4. numerous tertiary (segmental) bronchi
          5. numerous subsegmental bronchi
          6. numerous bronchioles
          7. numerous alveolar ducts
          8. numerous alveoli
            1. the basic unit of gas exchange
        2. right
          1. composed of three lobes
            1. superior
            2. middle
            3. inferior
          2. one right mainstem bronchus
            1. shorter, straighter, wider than the left
            2. most aspirated foreign objects lodge in this mainstem bronchus
          3. three secondary (lobar) bronchi
            1. one into each lobe of the right lung
          4. numerous tertiary (segmental) bronchi
          5. numersous subsegmental bronchi
          6. numerous bronchioles
          7. numerous terminal bronchioles
          8. numerous aveolar ducts
          9. numerous aveoli
            1. the basic unit of gas exchange
      6. pleurae
        1. sac enveloping the lungs
        2. composed of visceral and parietal pleura
          1. visceral pleura
            1. overlies the lung parenchyma
          1. parietal pleura
            1. lines the chest wall
      7. trachea and bronchial tree
      8. mechanics of respiration
        1. ventilation
          1. the physical process of moving air into and out of the lungs
          2. influenced by volume and intrapulmonary (inside the lung) and intrapleural (inside the pleura) pressure changes in the thoracic cavity
            1. at rest
              1. intrapulmonary pressure normally is 760 mm Hg
              2. intrapleural pressure normally is 756 mm Hg
              3. atmospheric pressure normally is 760 mm Hg
            2. during inspiration
              1. the diaphragm contracts and flattens out to increase the diameter of the thoracic cavity
              2. the external intercostal muscles contract, elevating the rib cage and moving the sternum forward to expand the lateral and anteroposterior diameter of the thoracic cavity
              3. intrapulmonary pressure drops to 758 mm Hg (2 mm Hg below atmospheric pressure)
              4. intrapleural pressure drops to 754 mm Hg
              5. the above sets up a pressure gradient
              6. as a result, atmospheric air rushes into the lungs from an area of high pressure (the atmosphere) to an area of low pressure (the lungs)
            3. during expiration
              1. the diaphragm relaxes and rises to its resting state
              2. the external intercostal muscles relax, the rib cage descends, and the sternum moves back to its resting state
              3. intrapulmonary pressure elevates to 763 mm Hg
              4. intrapleural pressure returns to 756 mm Hg
              5. the above sets up a pressure gradient
              6. as a result, pulmonary air rushes out into the atmosphere from an area of high pressure (the lungs) to an area of low pressure (the atmosphere)
      9. regulation of breathing
        1. chemosensitive area in the pons and medulla oblongata
          1. highly sensitive to increases in PaCO2 and hydrogen ion concentration
            1. increased PaCO2 and hydrogen ion concentration (acid pH) leads to increased rate and depth of respiration
            2. decreased PaCO2 and hydrogen ion concentration (alkaline pH) leads to decreased rate and depth of respiration
        2. chemoreceptors in the carotid and aortic bodies
          1. highly sensitive to decreased PaO2
            1. decreased PaO2 leads to increased rate and depth of respiration
            2. increased PaO2 leads to decreased rate and depth of respiration
          2. also known as the "hypoxic" drive to breath
            1. lung conditions, such as emphysema, cause patients to live with continuously increased PaCO2 levels so they are dependent on this drive, not in decreased PaCO2 levels, to breath
            2. consequently, patients with chronic lung conditions should receive only low concentrations of supplemental O2!
  3. pertinent history
    1. adults
      1. cough
      2. shortness of breath
      3. chest pain with breathing
      4. past history of respiratory infections
      5. cigarette smoking
      6. environmental exposure
      7. self-care behaviors
      8. usual state of health
    2. additional history for infants and children
      1. frequent colds
      2. history of allergies in the family
      3. measures take to childproof home
      4. smokers in the home
    3. additional history for the aging adult
      1. shortness of breath or fatigue with daily activities
      2. usual amount of daily activity
      3. chest pain with breathing
  4. preparation of the patient and environment
    1. patient
      1. greet the patient and establish rapport
      2. explain the procedure to the patient in simple terms what will be done, what he/she should expect, and how he/she can cooperate during the examination
      3. assist the patient in assuming a position of sitting up straight with his/her legs dangling over an examining table and then lying supine on an examining table with his/her head elevated 30 degrees on a small pillow and his/her arms at his/her sides
      4. encourage the patient to ask questions and mention any discomfort he/she feels during the examination
    2. environment
      1. private
      2. adequately lit
      3. warm
      4. quiet
  5. techniques of examination
    1. inspect the rate, rhythm, pattern, depth, sound, and effort of respirations
      1. observe the rate, rhythm, pattern, depth, sound, and effort of respirations from all angles
      2. normal findings:
        1. normal respiratory rate
          1. e.g., 12 - 20/minute
        2. regular rhythm
        3. even
        4. normal depth
          1. e.g., 500 - 800 milliters
        5. quiet
        6. unlabored
      3. deviations from normal findings:
        1. apnea
          1. breathing pattern evidenced by absence of respirations
        2. tachypnea, hypernea, hyperventilation
          1. breathing pattern evidenced by rapid (greater than 20 per minute), shallow respirations
        3. bradypnea
          1. breathing pattern evidenced by slow (less than 12 per minute) respirations
        4. Cheyne-Stokes
          1. breathing pattern evidenced by periods of deep breathing that alternate with periods of apnea in a regular pattern
        5. ataxic (Biot's)
          1. breathing pattern evidenced by periods of deep breathing that alternate with periods of apnea in an irregular pattern
        6. sighing
          1. breathing pattern evidenced by frequent sighing
        7. obstructive
          1. breathing pattern evidenced by normal inspiration and prolonged expiration
        8. dyspnea
          1. breathing pattern evidenced by a subjective feeling of difficulty or distressful respirations
    2. inspect the shape and configuration of the posterior thorax
      1. observe the shape and configuration of the posterior thorax from all angles
      2. normal findings:
        1. eliptical shape
        2. anterior - posterior diameter less than the traverse diameter (1:2 ratio)
        3. ribs slope downward and insert into the spine at a 45 degree angle
        4. costal angle less than 90 degrees
        5. sternum even with the ribs
      3. deviations from normal findings:
        1. barrel chest
          1. AP = transverse diameter; costal angle greater than 90 degrees; rib slope 45 degrees or horizontal; sternum positioned even with the ribs
        2. funnel chest (pectus excavatum)
          1. AP less than transverse diameter; costal angle 90 degrees; rib slope less than 45 degrees; sternum depressed
        3. pigeon chest (pectus carniatum)
          1. AP greater than transverse diameter; costal angle greater than 90 degrees; rib slope less than 45 degrees; sternum protruding
    3. inspect the respiratory movement of the posterior thorax
      1. observe the respiratory movement of the posterior thorax, by:
        1. standing directly behind the patient
        2. observing the respiratory movement of the patient's posterior thorax from all angles
      2. normal findings:
        1. symmetry
      3. deviations from normal findings:
        1. unilateral lag (or delay)
    4. inspect the skin over the posterior thorax
      1. observe the skin over the posterior thorax, by:
        1. standing directly behind the patient
        2. observing the skin over the patient's posterior thorax from all angles
      2. normal findings:
        1. skin intact, similar in color to the rest of the body
        2. skin thin, smooth, firm, and even
      3. deviations from normal findings:
        1. pallor, cyanosis
        2. skin very thin, shiny, atrophic
        3. redness
        4. lesions
        5. edema
        6. lumps
        7. nodules
        8. crusts
        9. scaliness
    5. inspect the spinal alignment of the posterior thorax
      1. observe the spinal alignment of the posterior thorax, by:
        1. standing directly behind the patient
        2. observing the spinal alignment of the patient's posterior thorax from all angles
      2. normal findings:
        1. spinous processes evenly and vertically aligned
      3. deviations from normal findings:
        1. kyphosis
          1. exaggerated convex curvature of the spinal column
        2. scoliosis
          1. exaggerated s-shaped curvature of the spinal column
        3. lordosis
          1. exaggerated concave curvature of the spinal column
    6. inspect the accessory muscles of the posterior thorax
      1. inspect the accessory muscles of the posterior thorax, by:
        1. standing directly behind the patient
        2. observing the accessory muscles of the patient's posterior thorax (sternocleidomastoid, scalenus, trapezius) from all angles
      2. normal findings:
        1. absence of the use of the accessory muscles during inspiration
        2. absence of hypertrophy of the accessory muscles
      3. deviations from normal findings:
        1. presence of the use of the accessory muscles during inspiration
        2. presence of hypertrophy of the accessory muscles
    7. inspect the intercostal spaces of the posterior thorax
      1. inspect the intercostal spaces of the posterior thorax, by:
        1. standing directly behind the patient
        2. observing the intercostal spaces of the patient's posterior thorax from all angles
      2. normal findings:
        1. absence of retraction into the intercostal spaces during inspiration
        2. absence of bulging into the intercostal spaces during expiration
      3. deviations from normal findings:
        1. presence of retraction into the intercostal spaces during inspiration
        2. presence of bulging into the intercostal spaces during expiration
    8. palpate the posterior thorax
      1. palpate the posterior thorax, by:
        1. standing directly behind the patient
        2. placing the pads of the first four fingers of your right hand over the right apice of patient's posterior thorax
        3. pressing the pads of the first four fingers of your right hand 1 centimeter (1/2 inch) into the right apice of the patient's posterior thorax
        4. moving the pads of the first four fingers of your right hand in a circle over the right apice of the patient's posterior thorax
        5. continuing to palpate and compare symmetrical areas of the patient's posterior thorax
      2. normal findings:
        1. nontender
        2. chest wall intact
        3. generalized warmth
      3. deviations from normal findings:
        1. tenderness
        2. nodules
        3. masses
        4. lumps
        5. depressions
        6. crepitus
        7. movable structures
        8. generalized coolness
        9. localized areas of warmth or coolness
    9. palpate the posterior thorax for respiratory expansion
      1. palpate the posterior thorax for respiratory expansion, by:
        1. standing directly behind the patient
        2. placing the thumb of your right hand on the right side of the 10th spinous process of the patient's right posterior thorax
        3. spreading the fingers of your right hand lightly over the 10th rib of the patient's right posterior thorax
        4. placing the thumb of your left hand on the left side of the 10th spinous process of the patient's left posterior thorax
        5. spreading the fingers of your left hand lightly over the 10th rib of the patient's left posterior thorax
        6. instructing the patient to inhale deeply and exhale fully
        7. observing the separation of your thumbs during the patient's inspiration
      2. normal findings:
        1. symmetrical separation of the thumbs during inspiration
        2. separation of the thumbs 3 - 5 centimeters (1 1/2 - 2 inches) during inspiration
      3. deviations from normal findings:
        1. asymmetrical separation of the thumbs during inspiration
        2. separation of the thumbs less than 3 - 5 centimeters (1 1/2 - 2 inches) during inspiration
    10. palpate the posterior thorax for tactile (vocal) fremitus
      1. palpate the posterior thorax for tactile (vocal) fremitus, by:
        1. standing directly behind the patient
        2. placing the ball (the bony part of the palm at the base of the fingers) or ulnar edge of one hand on the right apice of the patient's posterior thorax
        3. instructing the patient to say "ninety-nine", "one-one-one", or "blue moon"
        4. feeling for the vibration on the ball (the bony part of the palm at the base of the fingers) or ulnar edge of your right hand
        5. continuing to palpate and compare symmetrical areas of the patient's posterior thorax for tactile (vocal) fremitus
      2. normal findings:
        1. symmetrical areas of tactile (vocal) fremitus
      3. deviations from normal findings:
        1. asymmetrical areas of tactile (vocal) fremitus
        2. areas of increased, decreased, or absent tactile (vocal) fremitus
    11. percuss the posterior thorax
      1. percuss the posterior thorax, by:
        1. standing directly behind the patient
        2. instructing the patient to cross his/her hands across his/her chest
        3. placing your hands in the correct position for percussion over the right apice of the patient's posterior thorax
        4. percussing on a point over the right apice of the patient's posterior thorax
        5. listening for the percussion note obtained during percussion over the right apice of the patient's posterior thorax
        6. continuing to percuss in a zig-zag pattern and compare symmetrical areas of the patient's posterior thorax for percussion notes
      2. normal findings:
        1. symmetrical areas of resonance over the lung tissue
        2. resonance down to the 8th - 10th rib at the level of the diaphragm
        3. dullness over the ribs, scapulae
      3. deviations from normal findings:
        1. asymmetrical areas of resonance over lung tissue
        2. areas of dullness, hyperresonace, flatness, and tympany over the lung tissue
    12. percuss the posterior thorax to determine the level of diaphragmatic dullness
      1. percuss the posterior thorax to determine the level of diaphragmatic dullness, by:
        1. gathering a skin-marking pen and ruler
        2. standing directly behind the patient
        3. instructing the patient to cross his/her arms across his/her chest
        4. placing your hands in the correct position for percussion on the 7th intercostal space (ICS) in the right scapular line (RSL) in an area of lung resonance of the patient's posterior thorax
        5. instructing the patient to exhale fully and hold it
        6. percussing downward in progressive steps from the 7th ICS in the RSL in the area of lung resonance of the patient's posterior thorax to the level of diaphragmatic dullness in the RSL of the patient's posterior thorax
        7. marking the point of diaphragmatic dullness on the RSL of the patient's posterior thorax with a skin marking pen
        8. instructing the patient to breath normally
        9. placing your hands in the correct position for percussion on the 7th intercostal space (ICS) in the left scapular line (LSL) in an area of lung resonance of the patient's posterior thorax
        10. instructing the patient to exhale fully and hold it
        11. percussing downward in progressive steps from the 7th ICS in the LSL in the area of lung resonance of the patient's posterior thorax to the level of diaphragmatic dullness in the LSL of the patient's posterior thorax
        12. marking the point of diaphragmatic dullness on the LSL of the patient's posterior thorax with a skin marking pen
        13. instructing the patient to breath normally
      2. normal findings:
        1. symmetrical areas of diaphragmatic dullness
        2. level of diaphragmatic dullness at the 8th - 10th rib
      3. deviations from normal findings:
        1. asymmetrical areas of diaphragmatic dullness
        2. level of diaphragmatic dullness above the 8th - 10th rib
    13. percuss the posterior thorax to determine diaphragmatic excursion
      1. percuss the posterior thorax to determine diaphragmatic excursion, by:
        1. gaterhing a skin-marking pen and ruler
        2. standing directly behind the patient
        3. instructing the patient to cross his/her arms across his/her chest
        4. placing your hands in the correct position for percussion on the mark you made in RSL that coincided with the level of diaphragmatic dullness
        5. instructing the patient to exhale fully and hold it
        6. percussing downward in progressive steps from the mark you made in the RSL that coincided with the level of diaphragmatic dullness to the new level of diaphragmatic dullness in the RSL of the patient's posterior thorax
        7. marking the new level of diaphragmatic dullness in the RSL of the patient's posterior thorax with a skin marking pen
        8. instructing the patient to breath normally
        9. measuring the distance between the two points of diaphragmatic dullness in the RSL of the patient's posterior thorax
        10. placing your hands in the correct position for percussion on the mark you made in LSL that coincides with the level of diaphragmatic dullness
        11. instructing the patient to exhale fully and hold it
        12. percussing downward in progressive steps from the mark you made in the LSL that coincided with the level of diaphragmatic dullness to the new level of diaphragmatic dullness in the LSL of the patient's posterior thorax
        13. marking the new level of diaphragmatic dullness in the LSL of the patient's posterior thorax with a skin marking pen
        14. instructing the patient to breath normally
        15. measuring the distance between the two points of diaphragmatic dullness in the LSL of the patient's posterior thorax
      2. normal findings:
        1. symmetrical levels of diaphragmatic excursion
        2. level of diaphragmatic excursion 5 - 6 centimeters ( 2 - 3 inches) in males
        3. level of diaphragmatic excursion 3 - 5 centimeters ( 1 1/2 - 2 inches) in females
      3. deviations from normal findings:
        1. asymmetrical levels of diaphragmatic excursion
        2. level of diaphragmatic excursion less than 5 - 6 centimeters ( 2 - 3 inches) in males
        3. level of diaphragmatic excursion less than 3 - 5 centimeters ( 1 1/2 - 2 inches) in females
    14. auscultate the posterior thorax for normal and adventitious breath sounds
      1. auscultate the posterior thorax for normal and adventitious breath sounds, by:
        1. gathering a stethoscope
        2. standing directly behind the patient
        3. instructing the patient to cross his/her hands across his/her chest
        4. placing the diaphragm of your stethoscope over the right apice of the patient's posterior thorax
        5. instructing the patient to take a deep breath through this/her mouth
        6. listening for the breath sound obtained during auscultation over the right apice of the patient's posterior thorax
        7. continuing to auscultate in a zig-zag pattern and compare symmetrical areas of the patient's posterior thorax for breath sounds
      2. normal findings:
        1. symmetrical breath sounds
        2. bronchovesicular breath sounds between the scapulae
        3. vesicular breath sounds over the lung periphery
      3. deviations from normal findings:
        1. asymmetrical breath sounds
        2. bronchial or vesicular breath sounds between the scapulae
        3. bronchial or bronchovesicular breath sounds over the lung periphery
        4. crackles (fine)
          1. high-pitched; "crackling" or "popping" sounds on inspiration that are not cleared by coughing
        5. crackles (coarse)
          1. low-pitched; "bubbling" or "gurgling" sounds on inspiration that may or may not be cleared by coughing
        6. friction rubs
          1. low-pitched; "grating" sounds on inspiration and expiration that are not cleared by coughing
        7. wheezes
          1. high-pitched; "musical", polyphonic (multiple notes in a chord) sounds on expiration that are not cleared by coughing
        8. rhonchi
          1. low-pitched; "snoring", monophonic (single notes in a chord) sounds on expiration that may or may not be cleared by coughing
        9. stridor
          1. high-pitched; "crowing", monophonic (single notes in a chord) sounds on inspiration that are not cleared by coughing
        10. absence of breath sounds
    15. auscultate the posterior thorax for bronchophony
      1. auscultate the posterior thorax for bronchophony, by:
        1. gathering a stethoscope
        2. standing directly behind the patient
        3. instructing the patient to cross his/her hands across his/her chest
        4. placing the diaphragm of your stethoscope over the questionable area on the patient's posterior thorax
        5. instructing the patient to say "99"
        6. listening to the "99" obtained during auscultation over the questionable area on the patient's posterior thorax
        7. continuing to ausculate for bronchophony any other questionable areas over the patient's posterior thorax
      2. normal findings:
        1. the number "99" sounds soft, muffled, and indistinct
      3. deviations from normal findings:
        1. the number "99" sounds loud, clear, and distinct
    16. auscultate the posterior thorax for egophony
      1. auscultate the posterior thorax for egophony, by:
        1. gathering a stethoscope
        2. standing directly behind the patient
        3. instructing the patient to cross his/her hands across his/her chest
        4. placing the diaphragm of your stethoscope over the questionable area on the patient's posterior thorax
        5. instructing the patient to say "e"
        6. listening to the "e" obtained during auscultation over the questionable area on the patient's posterior thorax
        7. continuing to ausculate for egophony any other questionable areas over the patient's posterior thorax
      2. normal findings:
        1. the letter "e" sounds like "eeeeee"
      3. deviations from normal findings:
        1. the letter "e" sounds like "ay"
    17. auscultate the posterior thorax for whispered pectoriloquy
      1. auscultate the posterior thorax for whispered pectoriloquy, by:
        1. gathering a stethoscope
        2. standing directly behind the patient
        3. instructing the patient to cross his/her hands across his/her chest
        4. placing the diaphragm of your stethoscope over the questionable area on the patient's posterior thorax
        5. instructing the patient to say "1 - 2 - 3"
        6. listening to the "1 - 2 - 3" obtained during auscultation over the questionable area on the patient's posterior thorax
        7. continuing to ausculate for whispered pectoriloquy any other questionable areas over the patient's posterior thorax
      2. normal findings:
        1. the numbers "1 - 2 - 3" sounds soft, muffled, and indistinct
      3. deviations from normal findings:
        1. the numbers "1 - 2 - 3" sounds loud, clear, and distinct
    18. inspect the rate, rhythm, pattern, depth, sound, and effort of respirations of the anterior thorax
      1. observe the rate, rhythm, pattern, depth, sound, and effort of respirations of the anterior thorax from all angles
      2. normal findings:
        1. normal respiratory rate
          1. e.g., 12 - 20/minute
        2. regular rhythm
        3. even
        4. normal depth
          1. e.g., 500 - 800 milliters
        5. quiet
        6. unlabored
      3. deviations from normal findings:
        1. apnea
          1. breathing pattern evidenced by absence of respirations
        2. tachypnea, hypernea, hyperventilation
          1. breathing pattern evidenced by rapid (greater than 20 per minute), shallow respirations
        3. bradypnea
          1. breathing pattern evidenced by slow (less than 12 per minute) respirations
        4. Cheyne-Stokes
          1. breathing pattern evidenced by periods of deep breathing that alternate with periods of apnea in a regular pattern
        5. ataxic (Biot's)
          1. breathing pattern evidenced by periods of deep breathing that alternate with periods of apnea in an irregular pattern
        6. sighing
          1. breathing pattern evidenced by frequent sighing
        7. obstructive
          1. breathing pattern evidenced by normal inspiration and prolonged expiration
        8. dyspnea
          1. breathing pattern evidenced by a subjective feeling of difficulty or distressful respirations
    19. inspect the shape and configuration of the anterior thorax
      1. observe the shape and configuration of the anterior thorax from all angles
      2. normal findings:
        1. eliptical shape
        2. anterior - posterior diameter less than the traverse diameter (1:2 ratio)
        3. ribs slope downward and insert into the spine at a 45 degree angle
        4. costal angle less than 90 degrees
        5. sternum even with the ribs
      3. deviations from normal findings:
        1. barrel chest
          1. AP = transverse diameter; costal angle greater than 90 degrees; rib slope 45 degrees or horizontal; sternum positioned even with the ribs
        2. funnel chest (pectus excavatum)
          1. AP less than transverse diameter; costal angle 90 degrees; rib slope less than 45 degrees; sternum depressed
        3. pigeon chest (pectus carniatum)
          1. AP greater than transverse diameter; costal angle greater than 90 degrees; rib slope less than 45 degrees; sternum protruding
    20. inspect the respiratory movement of the anterior thorax
      1. observe the respiratory movement of the anterior thorax, by:
        1. standing on the right side of the patient
        2. observing the respiratory movement of the patient's anterior thorax from all angles
      2. normal findings:
        1. symmetry
      3. deviations from normal findings:
        1. unilateral lag (or delay)
    21. inspect the skin over the anterior thorax
      1. observe the skin over the anterior thorax, by:
        1. standing on the right side of the patient
        2. observing the skin over the patient's anterior thorax from all angles
      2. normal findings:
        1. skin intact, similar in color to the rest of the body
        2. skin thin, smooth, firm, and even
      3. deviations from normal findings:
        1. pallor, cyanosis
        2. skin very thin, shiny, atrophic
        3. redness
        4. lesions
        5. edema
        6. lumps
        7. nodules
        8. crusts
        9. scaliness
    22. inspect the accessory muscles of the anterior thorax
      1. inspect the accessory muscles of the anterior thorax, by:
        1. standing on the right side of the patient
        2. observing the accessory muscles of the patient's anterior thorax (sternocleidomastoid, scalenus, trapezius, rectus abdominis, pectoral) from all angles
      2. normal findings:
        1. absence of the use of the accessory muscles during inspiration
        2. absence of hypertrophy of the accessory muscles
      3. deviations from normal findings:
        1. presence of the use of the accessory muscles during inspiration
        2. presence of hypertrophy of the accessory muscles
    23. inspect the intercostal spaces of the anterior thorax
      1. inspect the intercostal spaces of the anterior thorax, by:
        1. standing on the right side of the patieint
        2. observing the intercostal spaces of the patient's anterior thorax from all angles
      2. normal findings:
        1. absence of retraction into the intercostal spaces during inspiration
        2. absence of bulging into the intercostal spaces during expiration
      3. deviations from normal findings:
        1. presence of retraction into the intercostal spaces during inspiration
        2. presence of bulging into the intercostal spaces during expiration
    24. inspect the supraclavicular spaces of the anterior thorax
      1. inspect the supraclavicular spaces of the anterior thorax, by:
        1. standing on the right side of the patient
        2. observing the supraclavicular spaces of the patient's anterior thorax from all angles
      2. normal findings:
        1. absence of retraction into the supraclavicular spaces during inspiration
        2. absence of bulging into the supraclavicular spaces during expiration
      3. deviations from normal findings:
        1. presence of retraction into the supraclavicular spaces during inspiration
        2. presence of bulging into the supraclavicular spaces during expiration
    25. inspect the substernal area of the anterior thorax
      1. inspect the substernal area of the anterior thorax, by:
        1. standing on the right side of the patient
        2. observing the substernal area of the patient's anterior thorax from all angles
      2. normal findings:
        1. absence of retraction into the substernal area during inspiration
        2. absence of bulging into the substernal area during expiration
      3. deviations from normal findings:
        1. presence of retraction into the substernal area during inspiration
        2. presence of bulging into the substernal area during expiration
    26. palpate the anterior thorax
      1. palpate the anterior thorax, by:
        1. standing on the right side of the patient
        2. placing the pads of the first four fingers of your right hand over the right apice of patient's anterior thorax
        3. pressing the pads of the first four fingers of your right hand 1 centimeter (1/2 inch) into the right apice of the patient's anterior thorax
        4. moving the pads of the first four fingers of your right hand in a circle over the right apice of the patient's anterior thorax
        5. continuing to palpate in a zig-zag pattern and compare symmetrical areas of the patient's anterior thorax
      2. normal findings:
        1. nontender
        2. chest wall intact
        3. generalized warmth
      3. deviations from normal findings:
        1. tenderness
        2. nodules
        3. masses
        4. lumps
        5. depressions
        6. crepitus
        7. movable structures
        8. generalized coolness
        9. localized areas of warmth or coolness
    27. palpate the anterior thorax for respiratory expansion
      1. palpate the anterior thorax for respiratory expansion, by:
        1. standing on the right side of the patient
        2. placing the thumb of your right hand to the left of the patient's xyphoid process
        3. spreading the fingers of your right hand lightly over the patient's left costal margin
        4. placing the thumb of your left hand to the right of the patient's xyphoid process
        5. spreading the fingers of your left hand lightly over patient's right costal margin
        6. instructing the patient to inhale deeply and exhale fully
        7. observing the separation of your thumbs during the patient's inspiration
      2. normal findings:
        1. symmetrical separation of the thumbs during inspiration
        2. separation of the thumbs 3 - 5 centimeters (1 1/2 - 2 inches) during inspiration
      3. deviations from normal findings:
        1. asymmetrical separation of the thumbs during inspiration
        2. separation of the thumbs less than 3 - 5 centimeters (1 1/2 - 2 inches) during inspiration
    28. palpate the anterior thorax for tactile (vocal) fremitus
      1. palpate the anterior thorax for tactile (vocal) fremitus, by:
        1. standing on the right side of the patient
        2. placing the ball (the bony part of the palm at the base of the fingers) or ulnar edge of one hand on the right apice of the patient's anterior thorax
        3. instructing the patient to say "ninety-nine", "one-one-one", or "blue moon"
        4. feeling for the vibration on the ball (the bony part of the palm at the base of the fingers) or ulnar edge of your right hand
        5. continuing to palpate in a zig-zag pattern and compare symmetrical areas of the patient's anterior thorax for tactile (vocal) fremitus
      2. normal findings:
        1. symmetrical areas of tactile (vocal) fremitus
      3. deviations from normal findings:
        1. asymmetrical areas of tactile (vocal) fremitus
        2. areas of increased, decreased, or absent tactile (vocal) fremitus
    29. percuss the anterior thorax
      1. percuss the anterior thorax, by:
        1. standing on the right side of the patient
        2. placing your hands in the correct position for percussion over the right apice of the patient's anterior thorax
        3. percussing on a point over the right apice of the patient's anterior thorax
        4. listening for the percussion note obtained during percussion over the right apice of the patient's anterior thorax
        5. continuing to percuss in a zig-zag pattern and compare symmetrical areas of the patient's anterior thorax for percussion notes
      2. normal findings:
        1. symmetrical areas of resonance over the lung tissue
        2. resonance down to the 6th rib at the level of the diaphragm
        3. flatness over muscle, bone
        4. dullness over the heart, liver
        5. tympany over the stomach
      3. deviations from normal findings:
        1. asymmetrical areas of resonance over lung tissue
        2. areas of dullness, hyperresonace, flatness, and tympany over the lung tissue
    30. auscultate the anterior thorax for normal and adventitious breath sounds
      1. auscultate the anterior thorax for normal and adventitious breath sounds, by:
        1. gathering a stethoscope
        2. standing on the right side of the patient
        3. placing the diaphragm of your stethoscope over the right apice of the patient's anterior thorax
        4. instructing the patient to take a deep breath through this/her mouth
        5. listening for the breath sound obtained during auscultation over the right apice of the patient's anterior thorax
        6. continuing to auscultate in a zig-zag pattern and compare symmetrical areas of the patient's anterior thorax for breath sounds
      2. normal findings:
        1. symmetrical breath sounds
        2. bronchial breath sounds over the trachea
        3. bronchovesicular breath sound over the sternum and the 1st and 2nd ICSs
        4. vesicular breath sounds over the lung periphery
      3. deviations from normal findings:
        1. asymmetrical breath sounds
        2. bronchial breath sounds over the 1st and 2nd ICSs or lung periphery
        3. bronchovesicular breath sounds over the trachea or lung periphery
        4. vesicular breath sounds over the trachea or 1st and 2nd ICSs
        5. crackles (fine)
          1. high-pitched; "crackling" or "popping" sounds on inspiration that are not cleared by coughing
        6. crackles (coarse)
          1. low-pitched; "bubbling" or "gurgling" sounds on inspiration that may or may not be cleared by coughing
        7. friction rubs
          1. low-pitched; "grating" sounds on inspiration and expiration that are not cleared by coughing
        8. wheezes
          1. high-pitched; "musical", polyphonic (multiple notes in a chord) sounds on expiration that are not cleared by coughing
        9. rhonchi
          1. low-pitched; "snoring", monophonic (single notes in a chord) sounds on expiration that may or may not be cleared by coughing
        10. stridor
          1. high-pitched; "crowing", monophonic (single notes in a chord) sounds on inspiration that are not cleared by coughing
        11. absence of breath sounds
    31. auscultate the anterior thorax for bronchophony
      1. auscultate the anterior thorax for bronchophony, by:
        1. gathering a stethoscope
        2. standing on the right side of the patient
        3. placing the diaphragm of your stethoscope over the questionable area on the patient's anterior thorax
        4. instructing the patient to say "99"
        5. listening to the "99" obtained during auscultation over the questionable area on the patient's anterior thorax
        6. continuing to ausculate for bronchophony any other questionable areas over the patient's anterior thorax
      2. normal findings:
        1. the number "99" sounds soft, muffled, and indistinct
      3. deviations from normal findings:
        1. the number "99" sounds loud, clear, and distinct
    32. auscultate the anterior thorax for egophony
      1. auscultate the anterior thorax for egophony, by:
        1. gathering a stethoscope
        2. standing on the right side of the patient
        3. placing the diaphragm of your stethoscope over the questionable area on the patient's anterior thorax
        4. instructing the patient to say "e"
        5. listening to the "e" obtained during auscultation over the questionable area on the patient's anterior thorax
        6. continuing to ausculate for egophony any other questionable areas over the patient's anterior thorax
      2. normal findings:
        1. the letter "e" sounds like "eeeeee"
      3. deviations from normal findings:
        1. the letter "e" sounds like "ay"
    33. auscultate the anterior thorax for whispered pectoriloquy
      1. auscultate the anterior thorax for whispered pectoriloquy, by:
        1. gathering a stethoscope
        2. standing on the right side of the patient
        3. placing the diaphragm of your stethoscope over the questionable area on the patient's anterior thorax
        4. instructing the patient to say "1 - 2 - 3"
        5. listening to the "1 - 2 - 3" obtained during auscultation over the questionable area on the patient's anterior thorax
        6. continuing to ausculate for whispered pectoriloquy any other questionable areas over the patient's anterior thorax
      2. normal findings:
        1. the numbers "1 - 2 - 3" sounds soft, muffled, and indistinct
      3. deviations from normal findings:
        1. the numbers "1 - 2 - 3" sounds loud, clear, and distinct

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This page was last modified on 1/1/02