Anatomy of the Thorax b. Complaints c. Inspection d. Pathological forms of the chest e. Breathing rate & types f. Palpation of the chest g. Percussion of chest h. Auscultation of chest

1. The Thorax & Lungs
Dilina Aarewatte
Group 9
Faculty of Medicine - თსსუ

2. Outline
- Anatomy of the Thorax
- Complaints
- Inspection
- Pathological forms of the chest
- Palpation of the chest
- Percussion of chest
- Deformities of chest

3. Anatomy of the Thorax
Landmarks:
- Lines of orientation
- Midsternal line
- Midclavicular lines
- Axillary lines
- Scapular line
- Vertebral line
- Anterior and posterior location of ribs

4. Special landmarks:
- 2nd intercostal space
- 4th intercostal space
- 4th thoracic vertebra
- Neurovascular structures.
Anatomy of the Thorax

5. - Apex of lungs
- Lower border of lungs
- Lobes
- Tracheobronchial tree
Anatomy of the Thorax : Lungs

6. Common complaints
- Chest pain
- Dyspnea (shortness of breath)
- Wheezing
- Cough
- Blood streaked sputum (hemoptysis)
- Daytime sleepiness/ snoring

7. Common complaints
- Chest pain : Sources → Pathology
○ The myocardium
○ The pericardium
○ The aorta
○ The trachea and large bronchi
○ The parietal pleura
○ The chest wall, including the
musculoskeletal and neurologic systems
○ The esophagus
○ Extrathoracic structures such as the neck,
gallbladder, and stomach

8. Examination
- Patient position
- Sitting
- Supine
- Patients who cannot sit-up
- Differences in lungs (when auscultated)

9. Examination
- Breathing:
- Rate
- Rhythm
- Depth
- Effort

10. Inspection
- Shape of chest
- Movement of chest
- Unilateral lag
Flail chest

11. Palpation
- Tenderness
- Skin changes
- Chest expansion
- Tactile fremitus

13. Percussion
- Anterior & lateral chest.
- Compare both sides.
- Listen for dullness.
- Technique for percussion:
- Percussion notes

14. Percussion : Findings seen in chest disorders

15. Thorax Deformities

16. Common underlying causes of CHEST PAIN

18. Thank you!
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19. 1. Title slide.
a. Title - Thorax & Lungs
b. Name - Dilina Aarewatte
2. Outline - what I will be covering in the ppt
a. Anatomy of the Thorax
b. Complaints
c. Inspection
d. Pathological forms of the chest
e. Breathing rate & types
f. Palpation of the chest
g. Percussion of chest
h. Auscultation of chest
3. Landmarks:
a. LINES
■ 2 can be seen (sternal & vertebral)
■ Others are imagined
b. Ribs - COUNT
■ learn to number the ribs and intercostal spaces
1. Put finger on suprasternal notch, move it 5cm down →
sternal angle
2. Adjacent to this → 2nd rib
3. Can walk down obliquely using 2 finger from here
4. In female displace breast laterally / palpate medially
4. Special landmarks
a. 2nd intercostal space
■ for needle insertion for tension pneumothorax.
b. 4th intercostal space
■ for chest tube insertion.
c. 4th Thoracic vertebra
■ for the lower margin of an endotracheal tube on a chest x-ray.
d. Neurovascular structures

20. ■ run along the inferior margin of each rib, so needles and tubes
should be placed just at the superior rib margins.
5. Lungs
a. Apex
■ Anteriorly, the apex of each lung rises approximately 2 to 4 cm
above the inner third of the clavicle
b. Lower border
■ Anteriorly -crosses the 6th rib at the midclavicular line and the
8th rib at the midaxillary line
■ Posteriorly, the lower border of the lung lies at about the level
of the T10 spinous process
c. Lobes
■ Each lung is divided roughly in half by an oblique (major)
fissure. This fissure may be approximated by a string that runs
from the T3 spinous process oblique down and around the
chest to the 6th rib at the midclavicular line.
■ right lungfurther divided by the horizontal fissure. Anteriorly,
this fissure runs close to the 4th rib and meets the oblique
fissure in the midaxillary line near the 5th rib. The right lung is
thus divided into upper, middle, and lower lobes (RUL, RML,
and RLL). The left lung has only two lobes, upper and lower
(LUL, LLL)
■ Each lung receives deoxygenated blood from its pulmonary
artery. Oxygenated blood returns from each lung to the left
atrium via the pulmonary veins.
d. Trachea & bronchial tree
■ Breath sounds over the trachea and bronchi are more harsh -
than those over the denser lung parenchyma.

21. ■ The trachea bifurcates into its mainstem bronchi at the levels
of the sternal angle anteriorly and the T4 spinous process
posteriorly (Figs. 8-11 and 8-12).
■ The right main bronchus is wider, shorter, and more vertical
than the left main bronchus and directly enters the hilum of the
lung.
■ The left main bronchus extends infero-laterally from below the
aortic arch and anterior to the esophagus and thoracic aorta
and then enters the lung hilum.
■ Each main bronchus then divides into lobar then into
segmental bronchi and bronchioles, terminating in the
sac-like pulmonary alveoli, where gas exchange occurs.
6. Complaints
■ Chest pain
1. raises concerns about the heart ( but often arise from
other structures in the thorax and lungs )
2. Start dual investigation of both thoracic and cardiac
causes
■ Dyspnea (shortness of breath)
1. painless but uncomfortable awareness of breathing
that is inappropriate to the level of exertion
2. Anxious patients may have episodic dyspnea during
both rest and exercise and also hyperventilation, or
rapid shallow breathing.
3. The degree of dyspnea, combined with spirometry, is a
key component of important COPD classification for
patient management.
4. Determining severity - Ask
a. How many steps or flights of stairs can the patient
climb before pausing for breath?
b. What about carrying bags of groceries,
vacuuming, or making the bed?
c. Has shortness of breath altered the patient’s

22. lifestyle and daily activities?
■ Wheezing
1. Wheezes are musical respiratory sounds that may be
audible to the patient and others
2. Wheezing occurs in partial lower airway obstruction
from secretions and tissue inflammation in asthma, or
from a foreign body
■ Cough
1. reflex response to stimuli that irritate receptors in the
larynx, trachea, or large bronchi
2. mucus, pus, blood, as well as external agents such as
allergens, dust, foreign bodies, or even extremely hot or
cold air
3. inflammation of the respiratory mucosa, pneumonia,
pulmonary edema, / compression of the bronchi or
bronchioles from a tumor or enlarged peribronchial
lymph nodes
4. Cough can signal left-sided heart failure
5. Assessment:
a. Establish the duration.
b. Is the cough acute, lasting less than 3 weeks;
subacute, lasting 3 to 8 weeks; or chronic, more
than 8 weeks?
c. Is cough dry? or produces sputum, or phlegm?
d. volume of any sputum and its color, odor, and
consistency.
■ Hemoptysis
1. blood coughed up from the lower respiratory tract; it
may vary from blood-streaked sputum to frank blood
2. quantify the volume of blood produced, the setting and
activity, and any associated symptoms
3. Bronchitis; malignancy; and cystic fibrosis and, less
commonly, bronchiectasis, mitral stenosis
■ Daytime sleepiness/ snoring
1. excessive daytime sleepiness and fatigue. Ask about
problems with snoring, witnessed apneas, awakening
with a choking sensation, or morning headache

23. 2. Hallmarks of
a. obstructive sleep apnea, commonly seen in
patients with obesity, posterior malocclusion of
the jaw (retrognathia), treatment-resistant
hypertension, heart failure, atrial fibrillation,
stroke, and type 2 diabetes.
7. Sources of pain
The myocardium Angina pectoris,
myocardial infarction,
myocarditis
The pericardium Pericarditis
The aorta Aortic dissection
The trachea and large
bronchi
Bronchitis
The parietal pleura Pericarditis, pneumonia,
pneumothorax, pleural
effusion, pulmonary
embolus
The chest wall, including
the musculoskeletal and
neurologic systems
Costochondritis, herpes
zoster
The esophagus Gastroesophageal reflux
disease, esophageal
spasm, esophageal tear
Extrathoracic structures
such as the neck,
gallbladder, and stomach
Cervical arthritis, biliary
colic, gastritis
8. Examination
a. Position
■ Sitting - Posterior thorax & lungs
■ Supine - anterior thorax and lungs
For women, this position allows the breasts to be gently
displaced. Some clinicians examine both the posterior and

24. anterior chest with the patient sitting, which is also
satisfactory.
b. For patients who cannot sit up, ask for assistance so that you can
examine the posterior chest in the sitting position. If this is not
possible, roll the patient to one side and then to the other.
c. Percuss and auscultate both lungs in each position. Because
ventilation is relatively greater in the dependent lung, you are more
likely to hear abnormal wheezes or crackles on the dependent side
9. Even though the respiratory rate might already be recorded, again carefully
observe the
a. rate,
b. rhythm,
c. depth, and
d. effort of breathing.
A healthy resting adult breathes quietly and regularly about 20 times a
minute.
Note whether expiration lasts longer than usual
10. Inspection
Standing in a midline position behind the patient, note the shape of the
chest and how the chest moves, including the following:
■ Deformities or asymmetry in chest expansion - Asymmetric expansion
occurs in large pleural effusions
■ Abnormal muscle retraction of the intercostal spaces during
inspiration,most visible in the lower intercostal spaces. - Retraction occurs
in severe asthma COPD, or upper airway obstruction
■ Impaired respiratory movement on one or both sides or a unilateral lag
(or delay) in movement
11. Palpate the anterior chest wall for the following purposes:
- Identification of tender areas
- Assessment of bruising, sinus tracts, or other skin changes
- Assessment of chest expansion.
- Place your thumbs along each costal margin, your hands
along the lateral rib cage .
As you position your hands, slide them medially a bit to raise

25. loose skin folds between your thumbs.
Ask the patient to inhale deeply.
Observe how far your thumbs diverge as the thorax expands,
and feel for the extent and symmetry of respiratory movement
- Tender pectoral muscles or costal cartilages suggest, (but do not
prove), that chest pain has a localized musculoskeletal origin.
-
12. Fremitus
a. Assessment of tactile fremitus.
If needed, compare both sides of the chest, using the ball or ulnar
surface of your hand.
Fremitus is usually decreased or absent over the precordium.
When examining a woman, gently displace the breasts as necessary
13. Percussion
a. As needed, percuss theanterior and lateral chest,
■ again comparing both sides
b. heart normally produces an area of dullness to the left of the
sternum from the 3rd to the 5th interspaces
c. Dullness represents airway obstruction from inflammation or
secretions.
d. Because pleural fluid usually sinks to the lowest part of the pleural
space (posteriorly in a supine patient), only a very large effusion can
be detected anteriorly.
e. The hyperresonance of COPD may obscure dullness over the heart.
f.

27. 14.

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