Physical Examination: Thorax

1. Physical Examination: Thorax

2. Thorax • Heart • Lungs • Inspect, palpate, percuss, auscultate

3. Anterior Chest Landmarks

4. 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..

5. 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.

6. Palpate – respiratory excursion.  Place hands over lower thorax (10th rib) with thumbs adjacent to spine should separate 1 ½” – method of determining equal expansion of the lungs

7. Percussion- adv. work. Range: resonance (hollow); hyper resonance (booming); dullness (masses, fluid

8. Anterior Thorax • .Inspect/ count respiratory 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).

9. Lateral Chest Landmarks

10. Inspection • Lesions • Chest excursion • Pattern of breathing • Obvious lesions

11. Palpation • Tender areas • Nodules • Fremitus • Chest excursion

12. 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.

13. listening for breath sounds: posterior

14. listening for breath sounds: lateral MENU p. 196.

15. listening for breath sounds: lateral MENU p. 196.

16. listening for breath sounds: anterior MENU p. 196.

17. Normal percussion notes: anterior MENU p. 198.

18. Normal percussion notes: posterior MENU p. 198.

19. Auscultation • breath sounds occur as a result of the movement of air through the trachea, bronchi and alveoli. • Use diaphragm; have client breath through mouth, more deeply than usual.

20. Visualize the right lung is divided into 3 lobes, the left, into two. Apex is at the top; base at the bottom. Sounds are assessed side-to-side; anterior and posterior.

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

23. Auscultation • Vesicular • bronchovescicular • Bronchial

24. Normal breath sounds: Vesicular • soft, low, heard in periphery and base of lungs. §; soft, low, heard in periphery and base of lungs.

25. Normal breath sounds: bronchovesicular • medium pitch, heard between scapula and anteriorly close to sternum.

26. Normal breath sounds: bronchial • loud and harsh; heard over trachea. Abnormal when heard elsewhere (pneumonia, tumor).

27. 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/tech.html • http://www.med.ucla.edu/wilkes/lungintro.htm

29. Assessment sites for the assessment of the precordium MENU p. 200.

30. 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.

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

32. 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/clinicalmed/heart.htm

34. 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

35. 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/MVPNormal.gif MENU

36. 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 MENU

37. 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. MENU

38. 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 • Forward flow through a steno tic valve • Increased flow through a normal valve • Backward flow through a valve that fails to close. MENU

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

40. Cardiac Cycle

41. Evaluating Heart Murmurs • Intensity • Graded on a scale of 1 to 6 Grade I (barely audible) to Grade VI (loud and may be heard without the stethoscope). • Pattern quality • Location • Radiation • Posture MENU

42. Peripheral Vascular System: assessment of BP, palpation of peripheral puses, inexpection of jugular and peripheral vessels and inspection of skin tissues to determine perfusion to the extremities.

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

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

45. 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.

46. 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+.

47. THE END