Describe abnormalities of the chest in two dimensions: Along the vertical axis

and Around the circumference of the chest

Note that the

12th rib is another possible starting point for counting ribs and

interspaces:

The inferior tip of the scapula is another useful bony landmark

Use a series of vertical lines, shown in the adjacent illustrations

The apex of each lung rises approximately

The lower border of the lung crosses

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 obliquely down and around the chest to the 6th rib at

the midclavicular line

The right lung is further divided by the horizontal (minor) fissure

Anteriorly, this fissure runs close to the 4th rib and meets the oblique

fissure in the midaxillary line near the 5th rib

Anatomical terms used to locate chest findings, such as:

Supraclavicular—above the clavicles

Infraclavicular—below the clavicles

Interscapular—between the scapulae

Infrascapular—below the scapulae

Bases of the lungs—the lowermost portions

Upper, middle, and lower lung fields

The trachea bifurcates into its mainstem bronchi at

The pleurae are serous membranes that cover the outer surface of each

lung

Their smooth opposing surfaces, lubricated by pleural fluid, allow the

lungs to move easily within the rib cage during inspiration and

expiration

The pleural space is the potential space between visceral and parietal

pleurae

Is quiet and easy—barely audible near the open mouth as a faint whish

When a healthy person lies supine, the breathing movements of the thorax are relatively slight. In contrast, the abdominal movements are usually easy to see

In the sitting position, movements of the thorax become more prominent

Extra work is required to breathe, and accessory muscles join the inspiratory effort

The sternomastoids are the most important of these, and the scalenes may become visible

Abdominal muscles assist in expiration

Chest pain

Shortness of breath (dyspnea)

Wheezing

Cough

Blood-streaked sputum (hemoptysis)

Complaints of chest pain or chest discomfort raise concern about

heart disease but often arise from structures in the thorax and lung as

well

To assess this symptom, you must pursue a dual investigation of both

and causes

The myocardium

The pericardium

The aorta

The trachea and large bronchi

The parietal pleura ,

The chest wall, including the musculoskeletal system and skin

The esophagus

Extrathoracic structures such as the neck, gallbladder, and stomach.

Your initial questions should be as broad as possible

As you proceed to the full history, ask the patient to point to where the

pain is in the chest

Watch for any gestures as the patient describes the pain

You should elicit all seven attributes of this symptom to distinguish

among the various causes of chest pain

Where is it? Does it radiate?

What is it like?

How bad is it?

When did (does) it start? How long does it last? How often does it come?

Include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness

Is there anything that makes it better or worse?

Have you noticed anything else that accompanies it?

A clenched fist over the sternum suggests

A finger pointing to a tender area on the chest wall suggests

A hand moving from neck to epigastrum suggests

Lung tissue itself has no pain fibers

Pain in lung conditions such as pneumonia or pulmonary infarction

usually arises from inflammation of the adjacent parietal pleura

Muscle strain from prolonged recurrent coughing may also be

responsible

The pericardium also has few pain fibers—the pain of pericarditis

stems from inflammation of the adjacent parietal pleura

Dyspnea

Is a Nonpainful but uncomfortable awareness of breathing

Is inappropriate to the level of exertion

Commonly termed shortness of breath

This serious symptom warrants a full explanation and assessment

because

Find out

Because of variations in age, body weight, and physical fitness, there is

no absolute scale for quantifying dyspnea

Determine Dyspnea severity based on the patient's daily activities

Carefully elicit the timing and setting of dyspnea, any associated

symptoms, and relieving or aggravating factors

Most patients with dyspnea relate shortness of breath to

their level of activity

Anxious patients present a different picture

Wheezes are musical respiratory sounds that may be audible to

the patient and to others

Wheezing suggests

Cough is a common symptom that ranges in significance from

Typically, cough is a reflex response to stimuli that irritate receptors

in the larynx, trachea, or large bronchi

These stimuli include

Other causes include inflammation of the respiratory mucosa and

pressure or tension in the air passages from a tumor or enlarged

peribronchial lymph nodes

Although cough typically signals a problem in the respiratory tract, it

may also be cardiovascular in origin

Cough can be a symptom of left-sided heart failure Duration of the cough is important:

Also consider

Foul-smelling sputum in

To help patients quantify volume, a multiple-choice question may be helpful

Large volumes of purulent sputum in bronchiectasis or lung abscess

Diagnostically helpful symptoms include fever, chest pain, dyspnea, orthopnea, and

wheezing

Hemoptysis is

Hemoptysis is rare in infants, children, and adolescents; it is seen most often in cystic fibrosis

Before using the term “hemoptysis,” try to confirm the source of the bleeding by both history and physical examination

Posterior thorax and lungs while the patient is

Anterior thorax and lungs with the patient

Try to visualize the underlying lobes, and compare one side with the other, so

that the

For men, arrange the patient's gown so that you can see the chest fully

With the patient sitting

Examine the posterior thorax and lungs

The with hands

resting, if possible, on the opposite shoulders

This position moves the scapulae partly out of the way and increases

your access to the lung fields. Then ask the patient to lie down

With the patient supine

The supine position makes it easier to examine women because the

breasts can be gently displaced

Furthermore, wheezes, if present, are more likely to be heard

For patients who cannot sit up without aid

Try to get help so that you can examine the posterior chest in the sitting

position

If this is impossible, roll the patient to one side and then to the other

Percuss the upper lung, and auscultate both lungs in each position

Because ventilation is relatively greater in the dependent lung, your chances of

hearing abnormal wheezes or crackles are greater on the dependent side

o Observe the , , , and of breathing

o A healthy resting adult breathes quietly and regularly about

times a minute

o An occasional is to be expected

o Note whether lasts longer than usual

o Always inspect the patient for any signs of

o Assess the patient's color for cyanosis

any relevant findings from earlier parts of your examination,

such as the shape of the fingernails

The respiratory rate is about 14-20 per min in normal adults and

up to 44 per min in infants

◦ Rapid shallow breathing has a number of causes, including

◦ Slow breathing may be secondary to such causes as

Rapid deep breathing has several causes, including

In the comatose patient, consider

Infarction

Hypoxia

Hypoglycemia affecting the midbrain or pons

◦ In obstructive lung disease, expiration is prolonged because

narrowed airways increase the resistance to air flow

◦ Causes include

Breathing punctuated by frequent sighs should alert you to

the possibility of hyperventilation syndrome—a common

cause of dyspnea and dizziness

◦ Periods of deep breathing alternate with periods of apnea (no breathing)

◦ Children and aging people normally may show this pattern in sleep

◦ Other causes include

◦ Ataxic breathing is characterized by unpredictable irregularity

◦ Breaths may be shallow or deep, and stop for short periods

◦ Causes include

Cyanosis signals hypoxia

Clubbing of the nails in

Lung Abscesses

Malignancy

Congenital Heart Disease

Listen to the patient's breathing

Audible stridor, a high-pitched wheeze, is an ominous sign of airway

obstruction in the larynx or trachea

Inspect the neck. During inspiration

Inspiratory contraction of the sternomastoids and scalenes at rest signals severe difficulty in breathing

Lateral displacement of the trachea in

Also observe the shape of the chest