chap

Physical Examination: Thorax

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Thorax

■ Heart
■ Lungs
■ Inspect, palpate, percuss, auscultate

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Anterior Chest Landmarks

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■ Anterior: Midsternal,
midclavicular, anterior
axillary
■ To identify the 2 ICS:
Palpate the clavicle and
follow it to the sternum;
note the suprasternal
notch. Follow the sternum
down and palpate the
bony ridge (manubrium);
move finger laterally to
find the 2nd rib. (The 2nd rib
is the first one felt since
the 1st rib is beneath the
clavicle). The 2nd ICS is
the space beneath the 2nd
rib.
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Posterior Chest Landmarks

■ anteroposterior diameter
compared with transverse
(NV 1:2)- AP diameter is
< transverse. A barrel
chest is associated with
pulmonary emphysema or
normal aging.
■ Note any retraction of the
interspaces during
inspiration- found in
emphysema, tracheal or
laryngeal obstruction.
Seen in newborns.
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■ Percussion- adv.
work. Range:
resonance (hollow);
hyper resonance
(booming); dullness
(masses, fluid
■

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■ .Inspect/ count respiratory

Anterior Thorax rate (15-20/min) and note
rhythm. Note respiratory
effort; use of neck
muscles or abdominal
breathing. Observe
intercostals spaces for
retraction (obstruction) or
bulging (emphysema).
■ Palpation- may palpate
for masses or crackling
feeling (cepitus-
subcutaneous air).

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Lateral Chest Landmarks

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Inspection

■ Lesions
■ Chest excursion
■ Pattern of breathing
■ Obvious lesions

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Palpation

■ Tender areas
■ Nodules
■ Fremitus
■ Chest excursion
■

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1. Tactile Fremitus: Normal lung

transmits a palpable vibratory
sensation to the chest wall. This is
referred to as fremitus and can be
detected by placing the ulnar
aspects of both hands firmly
against either side of the chest
while the patient says the words
"Ninety-Nine." This maneuver is
repeated until the entire posterior
thorax is covered. The bony
aspects of the hands are used as
they are particularly sensitive for
detecting these vibrations.

■
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listening for breath sounds: posterior

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listening for breath sounds: lateral

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p. 196.
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listening for breath sounds: lateral

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p. 196.
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listening for breath sounds: anterior

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p. 196.
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Normal percussion notes: anterior

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p. 198.
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Normal percussion notes: posterior

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p. 198.
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Auscultation
■ breath sounds occur as a result of the
movement of air through the
■ Visualize theright
trachea,
bronchi and alveoli.
lung is divided into 3
lobes, the left, into
■ Use diaphragm; have client breath
two. Apex is at the
through mouth, more deeply
top; base than usual.
at the
■ bottom. Sounds are
assessed side-to-
side; anterior and
posterior.

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 The middle lobe is
best assessed on
the right side under
the arm

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Normal breath sounds: Vesicular

■ soft, low, heard in

periphery and base of
 ; soft, low, heard in periphery and base of lungs. lungs.
■

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Normal breath sounds:

bronchovesicular
■ medium pitch,
heard between
scapula and
anteriorly close
to sternum.

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Normal breath sounds: bronchial

■ loud and harsh; heard

over trachea.
Abnormal when heard
elsewhere
(pneumonia, tumor).

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Abnormal breath sounds

■ Adventitious (abnormal) breath sounds occur when air
passes through narrowed airways filled with fluid or
mucus; superimposed over normal breath sounds.
■ Crackles, fine rales fine, high pitched crackling sound;
■ Rhonchi, course- low pitched, gurgling; moaning,
snoring quality, clear with coughing
Wheezes, high pitched, squeaky inspiratory, expiratory
■ http://depts.washington.edu/~physdx/pulmonary/tec
h.html
■ http://www.med.ucla.edu/wilkes/lungintro.htm

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Assessment sites for the assessment of

the precordium

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p. 200.
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■ Heart lies behind and to

the left of the sternum.
The upper portion or atria
(BASE) lies to the back;
the ventricles (APEX)
points forward, the apex
of the left ventricle
actually touches the
anterior chest wall near
the left midclavicular line
at or near the 5th left ICS.
Known as point of
maximal impulse (PMI)
and is where apical beat
is assessed. Impulse is a
good index of heart size.

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■ Known as point of
maximal impulse
(PMI) and is where
apical beat is
assessed. Impulse is
a good index of heart
size.

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■ Aortic area- 2nd ICS to

right of sternum (closure
of the aortic valve loudest
here).
■ Pulmonic area- 2nd ICS
to left of sternum (closure
of the pulmonic valve
loudest here).
■ Tricuspid- 5th ICS left of
sternal border (closure of
tricuspid valve).
■ Mitral- 5th ICS left of the
sternum just medial to
MCL (closure of mitral
valve).
■ http://medicine.ucsd.edu/c
linicalmed/heart.htm
■
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■ Inspection- look for lift at apex.

■ Auscultation- Client should be assessed in
supine position with head up to 45 deg.;
examiner stands at right side. Use
diaphragm for basic sounds; bell for
murmurs and extra sounds.
■ Identify the heart rate, rhythm; bell for
murmurs aortic, pulmonic, mitral
■
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Auscultating Heart Sounds

■ http://www-medlib.med.utah.edu/kw/pharm/hyper_heart1.html

■ Blood flows from R. atrium to R. ventricle through

the atrioventricular valve, the tricuspid. Blood
flows from L. atrium to L. ventricle through the
mitral valve. Blood passes from R. ventricle to
pulmonary artery through the pulmonic valve and
from the left ventricle to aorta through the aortic
valve (semilunar valves). Events on the left side
of the heart slightly precede those on the right.
■ http://www.austincc.edu/adnlev1/rnsgskills2online/physical_assessment_b/MVPNor
mal.gif

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Auscultating Heart Sounds

■ S1 produced by closure of the
atrioventricular valves, mitral and
tricuspid)- loudest at mitral area. The
sound is a dull, low pitched “lub.”
■ S2 (produced by closure of aortic and
pulmonic valve) is higher pitched, shorter
and is the “dub” sound. Heard best at the
base (aortic and pulmonic areas). S-2 is
normally louder than S-1

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Auscultating Heart Sounds

– S3 rapid filling of the ventricle with
blood; heard following S-2. Can be
normal in young adults and children;
pathologic in elderly
– S4 atrial contraction and thought to
result from stiffened left ventricle;
directly precedes S-1. Heard in
elderly.

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Auscultating Heart Sounds

■ Extra Heart Sounds snaps and clicks refer to
valves: aortic and mitral stenosis, prosthetic
valve
– Murmurs: swishing or blowing sounds caused
by
o Forward flow through a steno tic valve
o Increased flow through a normal valve
o Backward flow through a valve that fails
to close.

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■ http://egeneralmedical.com/listohearmur.html
http://depts.washington.edu/~physdx/heart/demo.html
■ to listen to sounds
http://www.med.ucla.edu/wilkes/Physiology.htm
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Cardiac Cycle

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Evaluating Heart Murmurs

■ Intensity
Peripheral Vascular ■
■ Graded on a scale of 1 to 6System:
Grade assessment
I (barely
audible) to Grade VI (loud and may
of BP, be heard
palpation of
without the stethoscope). peripheral puses,
inexpection of jugular
■ Pattern quality
and peripheral vessels
■ Location and inspection of skin
tissues to determine
■ Radiation perfusion to the
extremities.
■ Posture
■

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■ Inspect neck for

pulsations and
jugular veins for
distention. JVD
refers to jugular
venous distention-
index of function
of the right atrium.
■

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■ Advanced
practitioners would
ausculate the
carotid artery for a
bruit (blowing or
swishing sound)
and palpate a thrill
(a vibrating
sensation).
■
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Inspect and palpate skin of

hands, feet and legs
■ for color, temperature and edema.
Unilateral coolness may be associated with
decreased blood flow and should be
correlated with pulse in that extremity.
■ Arterial insufficiency- cool extremity, dec.
or absent pulse, color changes.
■ Venous insufficiency- normal temperature,
normal pulses, color changes; skin
changes.

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Inspect and palpate skin of

hands, feet and legs
■ Deep vein thrombosis (DVT)- Homan’s
sign: Knee flexed- pain in calf with
dorsiflexion of foot. Not performed if pt. is
dx’d with thrombus.
■ Edema- fluid accumulation in the tissues;
assess by pressing firmly with the thumb-
usually over shin or medial maleolus of
foot. Graded on scale of 1+ - 4+.
■

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1 Physical Examination: Thorax
2 Thorax
3 Anterior Chest Landmarks
4 "Anterior"
5 Posterior Chest Landmarks
6 "Palpate – respiratory excursion"
7 "Percussion- adv"
8 Anterior Thorax
9 Lateral Chest Landmarks
10 Inspection
11 Palpation
12 "Tactile Fremitus"
13 listening for breath sounds: posterior
14 listening for breath sounds: lateral
15 listening for breath sounds: lateral
16 listening for breath sounds: anterior
17 Normal percussion notes: anterior
18 Normal percussion notes: posterior
19 Auscultation
20 "Visualize the right lung is..."
21 "The middle lobe is best..."
22
23 Auscultation
24 Normal breath sounds: Vesicular
25 Normal breath sounds: bronchovesicular
26 Normal breath sounds: bronchial
27 Abnormal breath sounds
28
29 Assessment sites for the assessment of the precordium
30 "Heart lies behind and to..."
31 "Known as point of maximal..."
32 "Aortic area- 2nd ICS to..."
33
34 "Inspection- look for lift at..."
35 Auscultating Heart Sounds
36 Auscultating Heart Sounds
37 Auscultating Heart Sounds
38 Auscultating Heart Sounds
39 Places to listen to sounds
40 Cardiac Cycle
41 Evaluating Heart Murmurs
42 "Peripheral Vascular System"
43 "Inspect neck for pulsations and..."
44 "Advanced practitioners would ausculate the..."
45 Inspect and palpate skin of hands, feet and legs
46 Inspect and palpate skin of hands, feet and legs
47 THE END