Surface Markings

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SURFACE MARKINGS OF THORACIC STRUCTURES PRESENTER -- DR.P.RAVINDER RAO MD (HOM) PG-XIV BATCH MODERATER -- DR.A.V.RAJESHWER RAO M Sc (Psychology), MD (HOM) P.G. GUIDE & ASST.PROFESSOR DEPARTMENT OF SURGERY

Transcript of Surface Markings

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SURFACE MARKINGS OF THORACIC STRUCTURES

PRESENTER--DR.P.RAVINDER RAO MD (HOM) PG-

XIV BATCH 

MODERATER--DR.A.V.RAJESHWER RAO

M Sc (Psychology), MD (HOM)

P.G. GUIDE & ASST.PROFESSOR

DEPARTMENT OF SURGERY

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PLAN OF STUDY Introduction Need for study Land marks of thorax Surface markings of thoracic structures Importance of thoracic surface markings Conclusion Bibliography

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Introduction

Surface anatomy: study of internal body structures as they relate to the overlying skin

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Need for study As medical personnel, we will be

examining the chest to detect evidence of disease.

Our examination consists of inspection, palpation, percussion, and auscultation.

To make these examinations, the physician must be familiar with the normal structure of the thorax and must have a mental image of the normal position of the lungs and heart in relation to identifiable surface landmarks.

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Land marks of thorax

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The suprasternal notch

It is situated in the midline between the medial ends of the clavicles and above the upper edge of the manubrium.

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The angle of Louis (sternal angle)

It is formed by the joint between the manubrium and body of the sternum.

It is an important landmark as the 2nd costal cartilages articulate on either side and by following this line onto the 2nd rib, further ribs and intercostal spaces can be identified.

The sternal angle corresponds to a horizontal point level with the intervertebral disc between T4 and T5.

Carina of trachea is at this level. Mediastinum is divided into superior and

inferior at this level.

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The costal margin It is formed by the lower borders of the cartilages of the 7th, 8th, 9th and 10th ribs and the ends of the 11th and 12th ribs.

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The xiphisternal joint

It is formed by the joint between the body of

thesternum and xiphisternum

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Vertebra prominence The first palpable spinous process

is that of C7 . (vertebra prominence).

C1–6 vertebrae are covered by the thick ligamentum nuchae.

The spinous processes of the thoracic vertebrae can be palpated and counted

in the midline posteriorly.

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The scapula

Is flat and triangular in shape and is located on the upper part of the posterior surface of the thorax. The superior angle lies opposite the spine of the second thoracic vertebra. The spine of the scapula is subcutaneous, and the root of the spine lies on a level with the spine of the third thoracic vertebra. The inferior angle lies on a level with the spine of the seventh thoracic vertebra. In slim subjects the superior angle, inferior angle, spine and medial (vertebral) border of the scapula are easily palpable.

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RIBSAnteriorly ribs are counted down starting from 2nd rib. There are 12 ribs and 11 interspaces. You can also count up from 12th rib. Inferior angle of scapula sits on 7th rib posteriorly.

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Lines of orientation

These are imaginary vertical lines used to

describe locations on the chest wall. These include:

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Midsternal Line: A vertical line down the middle of sternum

Parasternal Line: A vertical line along lateral edge of sternum

Mid-Clavicular Line: A vertical line from middle of clavicle

Anterior Axillary Line: A vertical line along anterior axillary fold

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Mid-Axillary Line: A vertical line at mid point between anterior and posterior axillary line.

Posterior Axillary Line: Along post axillary fold

Scapular Line: Inferior angle of scapula

Vertebral line: Over spinous processes in the midline

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Anterior imaginary lines and landmarks

epigastric angle

Infraclavicular fossa

Mid sternal line

Suprasternal fossa Supraclavicular fossa

Para sternal line

Midclavicular line

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Lateral imaginary lines

Anterior axillary line

Midaxillary line

Posterior axillary line

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Posterior imaginary lines and landmarks

Scapular line

Posterior midline

Infrascapular region

Interscapular region

Suprascapular region

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SPACESAnteriorly there are supra clavicular, infraclavicular, precardiac and Traube's space. Posteriorly we have interscapular, supra, and infra scapular spaces.

Infraclavicular: Space below clavicle Supraclavicular: Space above clavicle Precardiac: Space in front of heart Traube's: Space overlying stomach Interscapular: Space between scapula Suprascapular: Space above scapula Infrascapular: Space below the scapula

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STRUCTURES IN THORAX

It includes the Breast externally, and internally on either sides Pleural sacs filled with Lungs, and in the middle Mediastinum.

Heart, and Great vessels present in the middle mediastinum

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Superior : trachea, thymus, brachiocephalic vein, aortic arch, esophagus thoracic duct

Middle: heart, ascending aorta, pulmonary trunk and veins, phrenic nerves

Posterior: esopahagus vagus nerves, descending aorta, thoracic duct, sympathetic trunks

Anterior: fat, connective tissue, thymus in child

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THE SURFACE MARKINGS OF THORACIC STRUCTURES

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MAMMARY GLAND

The mammary gland lies in the superficial fascia covering the anterior chest wall.

In the young adult female, it overlies the second to the sixth ribs and their costal cartilages and extends from the lateral margin of the sternum to the Midaxillary line.

Its upper lateral edge extends around the lower border of the pectoralis major and enters the axilla.

The position of the nipple is variable in the female but in the male it is usually in the 4th intercostal space in the midclavicular line.

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TRACHEA The trachea extends from the lower border of

the cricoid cartilage (opposite the body of the 6th cervical vertebra) in the neck to the level of the sternal angle in the thorax.

It commences in the midline and ends just to the right of the midline by dividing into the right and left principal bronchi.

At the root of the neck it may be palpated in the midline in the suprasternal notch.

The bifurcation occurs at the level of the sternal angle (T4-T5).

 

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The pleura The cervical pleura bulges upward into the

neck and has a surface marking identical to that of the apex of the lung.

A curved line may be drawn, convex upward, from the sternoclavicular joint to a point 1 in. (2.5 cm) above the junction of the medial and intermediate thirds of the clavicle.

The anterior border of the right pleura runs down behind the sternoclavicular joint, almost reaching the midline behind the sternal angle. It then continues downward until it reaches the xiphisternal joint.

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The pleura(Conti.) The anterior border of the left pleura

has a similar course, but at the level of the fourth costal cartilage it deviates laterally and extends to the lateral margin of the sternum to form the cardiac notch. (Note that the pleural cardiac notch is not as large as the cardiac notch of the lung-forms cardiac recess) It then turns sharply downward to the xiphisternal joint.

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The pleura(Conti.) The lower border of the pleura on both sides

follows a curved line, which crosses the 8th rib in the midclavicular line and the 10th rib in the Midaxillary line, and reaches the 12th rib adjacent to the vertebral column that is, at the lateral border of the erector spinae muscle.

Note that the lower margins of the lungs cross the 6th, 8th, and 10th ribs.

The distance between the two borders corresponds to the costodiaphragmatic recess.

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The lungs The apex of the lung projects

into the neck. It can be mapped out on the anterior surface of the body by drawing a curved line, convex upward, from the sternoclavicular joint to a point 1 in. (2.5 cm) above the junction of the medial and intermediate thirds of the clavicle.

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The lungs (Conti..) The anterior border of the right lung begins

behind the sternoclavicular joint and runs downward, almost reaching the midline behind the sternal angle. It then continues downward until it reaches the xiphisternal joint. The anterior border of the left lung has a similar course, but at the level of the fourth costal cartilage it deviates laterally and extends for a variable distance beyond the lateral margin of the sternum to form the cardiac notch. This notch is produced by the heart displacing the lung to the left. The anterior border then turns sharply downward to the level of the xiphisternal joint.

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The lungs (Conti..) The lower border of the lung in mid

inspiration follows a curving line, which crosses the 6th rib in the midclavicular line and the 8th rib in the Midaxillary line, and reaches the 10th rib adjacent to the vertebral column posteriorly. It is important to understand that the level of the inferior border of the lung changes during inspiration and expiration.

The posterior border of the lung extends downward from the spinous process of the 7th cervical vertebra to the level of the 10th thoracic vertebra and lies about 1.5 in. (4 cm) from the midline.

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The lungs (Conti..) The oblique fissure of the lung can

be indicated on the surface by a line drawn from the root of the spine of the scapula (level of spine of T3) obliquely downward, laterally and anteriorly, following the course of the sixth rib to the sixth costochondral junction.

In the left lung the upper lobe lies above and anterior to this line; the lower lobe lies below and posterior to it.

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The lungs (Conti..) In the right lung is an additional fissure, The horizontal fissure, which may

be represented by a line drawn horizontally along the fourth costal cartilage to meet the oblique fissure in the Midaxillary line.

Above the horizontal fissure lies the upper lobe and below it lies the middle lobe; below and posterior to the oblique fissure lies the lower lobe.

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The lungs (Conti..) The lungs sit within the pleural sacs and

follow the contours of the sacs with two important deviations:

1) The left lung has a cardiac notch around the ventricles of the heart. This is a region where the lung tissue is absent.

2) Also the lungs do not project into the lowest aspects of the pleural sacs. These regions are referred to as the pleural reflections or recesses.

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Lung surface markings REMEMBER: 2,4,6,8,10 Lungs

Each lung extends 3cm above the clavicle (apex)

Anterior borders of lungs are closest at the sternal angle – 2nd costal cartilage (cc)

Both reach to 4thcc Left:

Moves away from the midline at the 4th cc

Right: Moves away from the midline at

the 6th cc Both cross the midclavicular

line at the 8th cc Both cross the midaxillary line

at the 10th cc

Note about pleura: They have the same surface markings as the lungs but reach further down to the 12th ccREMEMBER: 2,4,6,8,10,12 Pleura

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Anterior view of lobes

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Right lateral view of lobes

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Left lateral view of lobes

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Posterior view of lobes

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THE HEART

For practical purposes, the heart may be considered to have an apex and four borders.

The apex, formed by the left ventricle, corresponds to the apex beat and is found in the fifth left intercostal space 3.5 in. (9 cm) from the midline, just medial to midclavicular line.

The superior border, formed by the roots of the great blood vessels, extends from a point on the second left costal cartilage (remember sternal angle) 0.5 in. (1.3 cm) from the edge of the sternum to a point on the third right costal cartilage 0.5 in. (1.3 cm) from the edge of the sternum.

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THE HEART (Conti..)

The right border, formed by the right atrium, extends from a point on the third right costal cartilage 0.5 in. (1.3 cm) from the edge of the sternum downward to a point on the sixth right costal cartilage 0.5 in. (1.3 cm) from the edge of the sternum. Almost in line with the SVC and IVC.

The left border, formed by the left ventricle and left auricle, extends from a point on the second left costal cartilage 0.5 in. (1.3 cm) from the edge of the sternum to the apex beat of the heart.

The inferior border, formed by the right ventricle and the apical part of the left ventricle, extends from the sixth right costal cartilage 0.5 in. (1.3 cm) from the sternum to the apex beat.

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THE HEART (Conti..)

The coronary sulcus can be indicated by a line from the third left, to the sixth right, sternocostal joint.

The anterior longitudinal sulcus is a finger’s breadth to the right of the left margin of the heart.

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Chapter 18, Cardiovascular System 43

Heart Anatomy

Figure 18.1

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Size, Shape, Location of the Heart Size of a closed

fist Shape

Apex: Blunt rounded point of cone

Base: Flat part at opposite of end of cone

Located in thoracic cavity in middle mediastinum

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Approximate location of the heart projected to the surface

Landmarks Superior R point: Is at

the superior border of the R 3rd costal cartilage

Superior L point: Is located at the inferior border of the L 2nd costal cartilage

Inferior L point: (the apex) is located at of the heart in the L 5th intercostal space

Inferior R point: Is located at the superior border of the 6th R costal cartilage

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Vessels returning blood to the heart include:1. Superior and inferior venae cavae2. Right and left pulmonary veins

Vessels conveying blood away from the heart include:

1. Pulmonary trunk, which splits into right and left pulmonary arteries

2. Ascending aorta (three branches) –a. Brachiocephalicb. Left common carotidc. Subclavian arteries

External Heart: Major Vessels of the Heart (Anterior View)

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Arteries – right and left coronary (in atrioventricular groove), marginal, circumflex, and anterior interventricular arteries

Veins – small cardiac, anterior cardiac, and great cardiac veins

External Heart: Vessels that Supply/Drain the Heart (Anterior

View)

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Chapter 18, Cardiovascular System 48

External Heart: Anterior View

Figure 18.4b

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Vessels returning blood to the heart include:1. Right and left pulmonary veins2. Superior and inferior venae cavae

Vessels conveying blood away from the heart include:1. Aorta2. Right and left pulmonary arteries

External Heart: Major Vessels of the Heart (Posterior View)

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Arteries – right coronary artery (in atrioventricular groove) and the posterior interventricular artery (in interventricular groove)

Veins – great cardiac vein, posterior vein to left ventricle, coronary sinus, and middle cardiac vein

External Heart: Vessels that Supply/Drain the Heart (Posterior

View)

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Chapter 18, Cardiovascular System 51

External Heart: Posterior View

Figure 18.4d

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Chapter 18, Cardiovascular System 52

Gross Anatomy of Heart: Frontal Section

Figure 18.4e

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Heart Valves Heart valves ensure unidirectional

blood flow through the heart Atrioventricular (AV) valves lie

between the atria and the ventriclesAV valves prevent backflow into the

atria when ventricles contractR-AV valve = tricuspid valveL-AV valve = bicuspid or mitral valve

Chordae tendineae anchor AV valves to papillary muscles

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Heart Valves (Conti..) Semilunar valves prevent backflow

of blood into the ventricles Aortic semilunar valve lies

between the left ventricle and the aorta

Pulmonary semilunar valve lies between the right ventricle and pulmonary

Have no chordae tendinae attachments

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Heart Valves (Conti..) Draw a line from the 3rd left costal cartilage to

the 6th right costal cartilage just lateral to the sternum. Write the letters P A B T from the top of this line to the bottom of the line, evenly spaced.

This represents the position of the pulmonary (P), aortic (A), bicuspid or mitral (B), and tricuspid (T) valves. While the above procedure allows you to map the anatomical position of the heart valves, this position is not the best place to hear the heart sounds.

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Heart Valves (Conti..) The pulmonary orifice- is situated in the upper

angle of the third left sternocostal articulation. The aortic orifice -is a little below and medial to

this, close to the articulation. The left atrioventricular opening -is opposite

the fourth costal cartilage, and rather to the left of the midsternal line.

The right atrioventricular opening-is a little lower, opposite the fourth intercostalspace of the right side.

The lines indicating the atrioventricular openings are slightly below and parallel to the line of the coronary sulcus.

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Heart Valves (Conti..) The best place to listen for the valves is

as follows: Aortic - 2nd right intercostal space just

lateral to sternum. Pulmonary - 2nd left intercostal space

just lateral to sternum. Bicuspid - at apex beat (5th inter costal

space just medial to midclavicular line). Tricuspid - Just to the left of the

xiphisternal joint.

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Heart Sounds Heart sounds (lub-dup) are

associated with closing of heart valves.First sound occurs as AV valves close and signifies beginning of systole (contraction).

Second sound occurs when SL valves close at the beginning of ventricular diastole (relaxation).

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Location of Heart Valves

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Heart Valves Atrioventricular

TricuspidBicuspid or

mitral Semilunar

AorticPulmonary

Prevent blood from flowing back

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63

Heart Valves

Figure 18.8a, b

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Heart Valves

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Mitral Valve Prolepses

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Artificial Heart

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PULMONARY TRUNK First mark the pulmonary valve by a

horizontal line 2.5 cm long, mainly along the upper border of the left 3rd costal cartilage and partly over the adjoining part of the sternum.

Then mark the pulmonary trunk by two parallel lines 2.5 cm apart from the pulmonary orifice upwards to the left 2nd costal cartilage.

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ASCENDING AORTA

First mark the aortic orifice by a slightly oblique line 2.5 cm long running downwards and to the right over the left half of the sternum beginning at the level of the lower border of the left 3rd costal cartilage.

Then mark the ascending aorta by two parallel lines 2.5 cm apart from the aortic orifice upwards to the right half of the sternal angle.

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ARCH OF AORTA

Arch of aorta lies behind the lower half of the manubrium sterni. Its upper convex border is marked by a line which begins at the right end of the sternal angle, arches upwards and to the left through the centre of the manubrium, and ends at the sternal end of the left 2nd costal cartilage.

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DESCENDING THORACIC AORTA

Descending thoracic aorta is marked by two parallel lines 2.5 cm apart, which begin at the sternal end of the left 2nd costal cartilage, pass downwards and medially, and end in the median plane 2.5 cm above the transpyloric plane.

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SUPPPERIOR VENA CAVA

Superior vena cava is marked by two parallel lines 2 cm apart, drawn from the lower border of the right first costal cartilage to the upper border of the 3rd right costal cartilage, overlapping the right margin of the sternum.

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BRACHIOCEPHALIC VEINS

Formed by the confluence of the internal jugular and subclavian veins.

This occurs posterior to the sternoclavicular joints.

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DIAPHRAGM

The central tendon of the diaphragm lies directly behind the xiphisternal joint.

In mid-inspiration the highest part of the right dome reaches as far as the upper border of the 5th rib in the mid-clavicular line.

The left dome reaches only the lower border of the 5th rib.

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IMPORTANCE OF THORACIC SURFACE

MARKINGS

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CHEST-INSPECTION

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Chest asymmetry

Kyphoscoliosis Larger hemi thorax :

(Pneumothorax, Pleural effusion)

Smaller hemi thorax: (Atelectasis, Pleural fibrosis, Agenesis of Lung)

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Increased pleural negative pressure.

Unilateral (airway obstruction) or bilateral (COPD, Asthma).

Intercostal and supraclavicular fossa retraction.

Downward movement of trachea with quiet inspiration.

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Respiratory Rate and Pattern of Breathing

The patient should not be aware that you are counting his respiratory rate. Count the respiratory rate while pretending to take the patient's pulse.

Note the rate, pattern and comfort of respiration.

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Respiratory Rate and Pattern of Breathing

Normal

Resting rate is between 10-14 per minute, regular with no apparent discomfort..

Chest wall and abdomen expand during inspiration and is symmetrical.

Abdominal component of expansion is dominant in men and thoracic component in women.

Periodic deep breathing (Sighs) less than 5 per minute.

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Abnormal Finding

Minor changes in rate and rhythm of respiration occur due to anxiety and while it may represent an abnormality, it may not be significant

Rate Rate below 10/min: Bradypnea:

(Narcotics, raised intracranial tension, myxedema)

Rate above 20/min: Tachypnea: (Interstitial, vascular and multitude of diseases, anxiety

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Pattern Periodic breathing. Cyclical increase

and decrease in depth of respiration: Cheyne-stokes breathing: (CHF, Cerebrovascular insufficiency)

Slow deep breathing: Kussmaul: (Ketoacidosis)

Totally irregular with no pattern:Biot's breathing: (CNS injury)

Periodic deep breathing: Sighs: (Anxiety state)

Instead of simultaneous chest and abdominal expansion with inspiration abdomen retracts while chest expands: Abdominal paradox: (Diaphragmatic paralysis)

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Pattern(Conti..)

On the side of unstable chest wall hemithorax retracts while the normal side expands with inspiration: Thoracic paradox: (Flail chest)

With lips pursed patient controls expiration slowly: Pursed lip breathing: (Obstructive lung disease)

No abdominal component : ( Acute abdomen)

No thoracic component: (Pleurisy, Chest wall pain, Ankylosing spondylitis)

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Discomfort Labored breathing: (Heart and Lung

diseases) Unable to assume supine position because

of worsening shortness of breath: Orthopnea: (CHF, Diaphragmatic paralysis, SVC syndrome, Anterior mediastinal mass)

Unable to erect position because of worsening shortness of breath, more comfortable in supine position : Platypnea: (Pulmonary spiders in cirrhotic)

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Symmetry of Hemi thorax

Both sides are equal in size and asymmetry is abnormal. Unilateral lung or pleural disease alters negative pressure in pleura, affecting the resting size of hemi thorax. e.g. In pneumothorax the negative pressure in pleura is lost and there is nothing to hold chest wall down. Hemi thorax on that side will assume TLC position. In patients with atelectasis the negative pressure in pleura increases and the size of hemi thorax will become smaller

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Symmetry of Hemi thorax(Conti..)

It is best to assess symmetry of hemi thorax with patient laying flat in bed without pillows. Stand either at head or foot end and look tangentially at the thorax level to asses asymmetry.

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Accessory Inspiratory Muscles

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CHEST-PALPATION

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Tactile Fremitus

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CHEST—PERCUSSION

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Percuss the lung fields, alternating, from top to bottom and comparing sides.

Percuss over the intercostal space and note the resonance and the feel of percussion.

Keep the middle finger firmly over the chest wall along intercostal space and tap chest over distal interphalangeal joint with middle finger of the opposite hand.

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Percussion-Normal

The lung is filled with air (99% of lung is air). Hence, percussion of it gives a resonance. This step helps identify areas of lung devoid of air.

Appreciate the dullness of the left anterior chest due to heart and right lower chest due to liver.

Note the hyper-resonance of the left lower anterior chest due to air filled stomach.

Normally, the rest of the lung fields are resonant.

Normal diaphragmatic excursion is 5-6 cm.

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Percussion- Abnormal

Dullness: (Mass, Atelectasis, Consolidation, Pleural effusion)

Hyper-resonance: (Emphysema, Asthma, Pneumothorax, Blebs)

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Percussion- Abnormal A portion of the area of the heart thus mapped out is

uncovered by lung, and therefore gives a dull note on percussion.

The remainder being overlapped by lung gives a more or less resonant note.

The former is known as the area of superficial cardiac dullness, the latter as the area of deep cardiac dullness.

The area of superficial cardiac dullness is somewhat triangular; from the apex of the heart two lines are drawn to the midsternal line, one to the level of the fourth costal cartilage, the other to the junction between the body and xiphoid process; the portion of the midsternal line between these points is the base of the triangle.

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CHEST-AUSCULTATION

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Lungs-Auscultation-Order

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Normal auscultatory sound

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MAIN

Rt. Superior lobarSuperior lobar

Middle lobar

Inferior lobarInferior lobar

Secondary (lobar) bronchi

Tertiary bronchi—one for each BPS

Inhaled objects generally are found in right bronchus due to straighter pathway

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Tracheal Breath Sounds: Loud, harsh, high pitched.

Bronchial Breath Sounds: Loud, high-pitched with air swishing past.

Bronchovesicular Sounds: Heard near branching of main bronchi, combination of bronchial and vesicular sounds.

Vesicular Sounds: Soft, low-pitched, airy, swishing, heard below the level of the bronchi

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Auscultation of Lungs- Normal There are two normal breath sounds.

Bronchial and vesicular. Breath sounds heard over the tracheobronchial tree are called bronchial breathing and breath sounds heard over the lung tissue are called vesicular breathing. The only place where tracheobronchial trees are close to chest wall without surrounding lung tissue are trachea, right sternoclavicular joints and posterior right interscapular space. These are the sites where bronchial breathing can be normally heard. In all other places there is lung tissue and vesicular breathing is heard

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Bronchial Breathing The bronchial breath sounds over the trachea has a higher pitch, louder, inspiration and expiration are equal and there is a pause between inspiration and expiration.

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Vesicular Breathing The vesicular breathing is

heard over the thorax, lower pitched and softer than bronchial breathing. Expiration is shorter and there is no pause between inspiration and expiration. The intensity of breath sound is higher in bases in erect position and dependent lung in decubitus position

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Vesicular Breathing(Conti..)

The breath sounds are symmetrical and louder in intensity in bases compared to apices in erect position. No adventitious sounds are heard.

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Abnormal Finding

Intensity of breath sounds, in general, is a good index of ventilation of the underlying lung. If the intensity increases there is more ventilation and vice versa. Breath sounds are markedly decreased in emphysema

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Bronchial breathing- anywhere other than over the trachea, right clavicle or right interscapular space is abnormal. Presence of bronchial breathing would suggest

Consolidation Cavitation Complete alveolar atelectasis with patent

airways Mass interposed between chest wall and

large airways Tension Pneumothorax Massive pleural effusion with complete

atelectasis of lung

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Experienced physicians could discriminate between consolidation and cavitation by noting the quality of bronchial breathing. In consolidation, the bronchial breathing is low pitched and sticky and is termed tubular type of bronchial breathing. In cavitary disease, it is high pitched and hollow and is called cavernous breathing. You can simulate this sound by blowing over an empty coke bottle. In tension pneumothorax bronchial breath sounds has a metallic quality and is called amphoric breathing

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PLEURAL FRICTION RUB: Grating sound heard during breathing that stops when the breath is held. Caused by friction of visceral and parietal pleura.

PULMONARY CONSOLIDATION: Occurs with late-stage lobar pneumonia.

BRONCHOPHONY: Increased transmission of sound to the lung periphery. Indicative of pulmonary consolidation

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WHISPERED PECTORILOQUY: Words being understood better when whispered. Also indicative of pulmonary consolidation.

EGOPHONY: "E" to "A" sound-changes. Indicative of pulmonary consolidation or pleural effusion.

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HAMMAN'S SIGN: Crunching, crackling sound over chest heard synchronous with the heart beat. Occurs with mediastinal emphysema -- air in the mediastinum.

CAUSES: Can follow thoracic surgery, trauma.

Boerhaave's Syndrome: Esophageal rupture causing air in mediastinum. Rare

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Atelectasis: Bronchial plug ------> decreased lung volume ------> higher lung density ------> lung mass is pulled toward chest wall by negative pressure

Tracheal deviation toward affected side

no breath sounds

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Bronchiectasis: Chronic bronchial dilation.

Caused by frequent pulmonary infections or pneumonia.

Large amounts of sputum will be expectorated when patient lies prone hanging toward floor.

Bronchitis: Acute (infectious) or chronic (smoker's)

Bronchiolitis: Common in infants and children

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‘pink puffer’. Note the pursed-lip breathing

.

‘Blue bloater’ showing ascites from marked cor

pulmonale.

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Conclusion Surface and regional anatomy are

important to a physician performing a physical exam, physicians must also understand the relationships of internal organs to interpret radiographs.

The position of the left nipple in males provides a guide for where to listen for various heart sounds.

Tracheal deviation could be either due to Lung, pleural, Mediastinal or Chest wall disease. The mediastinum can be either pulled or pushed away from the lesion.

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Without proper knowledge of surface markings physicians may do harm to patients like-e.g.

A 52-year-old woman was admitted to the hospital with a diagnosis of right-sided pleurisy with pneumonia. It was decided to remove a sample of pleural fluid from her pleural cavity. The resident inserted the needle close to the lower border of the eighth rib in the anterior axillary line. The next morning he was surprised to hear that the patient had complained of altered skin sensation extending from the point where the needle was inserted downward and forward to the midline of the abdominal wall above the umbilicus.

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The reason is needle was inserted too close to the lower border of the eighth rib and damaged the eighth intercostal nerve.

Anatomy of the Intercostal Space—VAN (Vein, Artery, and Nerve) Immediately below the rib above downwards.

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Anatomy of the Intercostal Space

Vein

Artery

Nerve

Immediately below rib

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BIBLIOGRAPHY

Anatomy of the Human Body, by Henry Gray.

Clinical Anatomy by Regions—by Richard S. Snell, 8th edition.

Human Anatomy, by B.D.Chaurasia, 4th edition.

www.gpnotebook.co.uk/simplepage.

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