CSM V

Anatomic review

Content of thorax cavity-parietal pleura, -pleural space, -visceral pleura, -lungs, -mediastinum (aorta, trachea, R and L mainstem bronchi, lymph nodes, vagus nerves, esophagus, heart), -part of the liver/spleen/kidneys/stomach

Structure of lungs, mechanics of respiration (from physio)Anterior thoracic cage + posterior thoracic cage (from anato)

Reference lines (slide)a)front-midsternal line-midclavicular line-anterior axillary line

b)behind-scapular line-vertebral line

c)z boku-anterior axillary line-posterior axillary line-midaxillary line

tracheal bifurcation T4 (posterior), sternal angle /Louis angle “little bump, its tracheal bifurcation” (anterior) look in book

suprascapular space, interscapular space, infrascapular space (on the back) learn according to lungs lobe

Brief Survey of chest and respiration-is the patient distress?-observe the rate, rhytm, and depth of respiration-audible sounds?-respirations should be easy, quiet, and regular

Respiratory Inspection-AP diameter of chest as compared to the lateral diameter (1/3 to ½) Barrel chest-Sternal abnormalities – pectus excavatum or pectus carinatum-Rate, depth, rhytm of respirations-Abnormal breathing pattern – Kussmaul-Skin color, clubbing (clubbed fingers, enlarged fingers)-Spinal curvatures - kyphosis, scoliosis, kyphoscoliosis

Visual Examination of the Chest (Breathing patterns)-Rate, depth, regularity,a)normal A:12-20/min, Infants:44/minb)Tachypnea (rapid, shallow)c)Hyperypnea (rapid, deep breathing, hyperventilation, kussmaul breathing-toxic condition affecting brain)d)Bradypneae)Ataxic breathing (Biots breathing, irregularly irregular)f) Cheyne-Stokes breathing (regular rate, irregular depts., MAY be normal)g)Sighs (hyperventilation syndrome, 1sigh per 200 breaths)

Configuration of Thorax (+rys)-normal adult-barrel chest-pectus excavatum-pectus carinatum

-scoliosis-kyphosis

Systemic signs of pulmonary disease – cyanosis (severe imparment of oxygen concentration in the blood)- clubbed fingers (sign of chronis respiratory insufficiency)- eyes (reddish colour)

Clues to increased work of breathing-nasal flaring-intercostal/supraclavicular retractions-accessory muscle use-pursed-lipped breathing-disrupted speech-thoraco-abdominal dissociation

Anterior chest-inspection-palpation-expansion-tactile gremitus-percussion auscultation

Posterior thorax-suspect for: shape, symmetry, deformity, skin lesions-palpate for tenderness or over any findings or abnormalities-thoracic spine-CVA percussion-respiratory expansion

Posterior chest-tactile fremitus-percussion-level of diaphragm-diapghragmatic excursion-auscultationa) diaphragmb) apices downwardsc) compare side to side

Tactile Examination of the Chest (Tactile fremitus)-palpable vibration of the chest wall from sounds transmitted from the phonating larynx-ninety-nine-compare symmetry-abnormality MAY be increased or decreased or absent

Abnormal Tactile Fremitus-Increased tactile f.-Decreased tactile f.-Rhonchal fremitus-Pleural Friction f.

Percussion-systematic-progress from apices to base-side to side-intensity, duration, and pitch-normal = resonance-note location of abnormalities

PathologyResonance-NLHyperresonance-too much air such as emphysema of pneumothoraxDullness-abnormal density due to possible pneumonia, pleural effusion, atelectasis or tumor