Introduction to the Practice of Medicine 1

THORAX EXAM DETAILS FROM THORAX EXAM VIDEO

WASH HANDS

1. Locate and identify the surface markings of the trachea and major bronchi
Location of trachea bifurcation into right and left mainstem bronchi:
< Anteriorly: at sternal angle=angle of Louis
< Posteriorly: at spinous process of T 4
Trachea should be in the midline or just slightly to the right of midline, and it runs from
the base of the neck inferiorly and then behind the manubrium of the sternum.

2. Locate and identify the suprasternal notch.
Above manubrium of the sternum, and between the two sternal heads of the
sternocleidomastoid

3. Locate and identify the sternal angle of Louis.
The boney ridge joining the manubrium to the body of the sternum
The second costal cartilages are adjacent to the sternal angle.

4. Locate and identify the xiphoid process.
The boney tip from the bottom of the body of the sternum in the midline

5. Counting ribs.
Anteriorly - The second costal cartilage is adjacent to the sternal angle. An intercostal
space is named by the rib above it. Posteriorly, the lowest rib is the twelfth rib. The
inferior angle of the scapula is located horizontally at the seventh rib or seventh
intercostal space.

6. Locate and identify the spinous process of C7 and T1.
These are the 2 most prominent spinous processes on the neck if the patient flexes the
neck.

7. Locate and identify the vertebral line.
A vertical line that runs over the middle of the spinous processes posteriorly

8. Locate and identify the inferior angle of the scapula.
Lowest part of the scapula, normally located horizontally at the 7
th
rib or 7
th
intercostal
space

9. Locate and identify the scapular line.
A vertical line that runs through the inferior angle of the scapula

10. Locate and identify the anterior axillary line.
A vertical line running inferiorly from the anterior axillary muscle fold

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Introduction to the Practice of Medicine 1

11. Locate and identify the posterior axillary line.
A vertical line running inferiorly from the posterior axillary muscle fold

12. Locate and identify the midaxillary line.
A vertical line that runs inferiorly from the dome of the axilla

13. Locate and identify the midsternal line.
A vertical line that runs through the middle of the sternum and xiphoid process

14. Locate and identify the midclavicular line.
A vertical line running through the midpoint of the clavicle and inferiorly

(The purpose of all the above is to help the student describe and locate findings vertically and
horizontally around the thorax.)

15. Locate and identify the surface markings of the lungs, fissures, and lobes.
LUNGS: Anteriorly, the apex of each lung rises about 2 4 cm above the inner third of
the clavicle. The lower border of the lung crosses the 6
th
rib at the midclavicular line.
Laterally: the lower lung border crosses the 8
th
rib at the midaxillary line.
Posteriorly: the lower border of the lung lies at about the level of T 10. During normal
breathing, the lower border of the lung may descend about 5-6 cm as the diaphragm
contracts.
FISSURES and LOBES: Each lung is roughly divided in half by an oblique=major
fissure. This fissure can be approximated by a line from T3 spinous process posteriorly
and then runs obliquely down and around the chest to the sixth rib in the midclavicular
line. Posteriorly, above this line are the upper lobes, and below is the lower lobe.

A horizontal=minor fissure also further divides the right lung. Anteriorly, this fissure
runs from about the 4
th
rib and then travels roughly horizontally around the chest wall to
the 5
th
rib in the midaxillary line. Above this fissure is RUL, and below is RML. Key
teaching point: The right middle lobe does not have a posterior projection. To exam the
RML, you need to auscultate/percuss in the lateral and anterior chest.

16. Test for respiratory expansion
Technique: First, the student should inspect the chest wall for symmetric expansion.
Second, the student places their hands on the lower posterior chest wall with their
thumbs at about the level of the 10
th
rib and parallel to the 10
th
rib. As the student grasps
the lower chest wall, they should slide their thumbs medially so that they raise a vertical
skin fold medial to their thumbs and lateral to the patients spine. Student should then
ask the patient to take a deep breath. As the patient breathes deeply, the students hands
and thumbs should move laterally and equally about 2 5 inches as the chest expands.
The skin fold the student created should also decrease in size as the chest wall expands.
If the student starts too close to the midline over the spine, there is usually not enough
loose skin available to create a skin fold.

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Introduction to the Practice of Medicine 1

17. Test for tactile fremitus
Purpose for examining for tactile fremitus: detects palpable vibrations transmitted
through the broncho- pulmonary tree to the chest wall. In a normal patient, both right
and left lungs have normal and equal/ symmetric vibrations that the examiner
appreciates. Increased, decreased, or absent tactile fremitus of one lung as compared to
the other is abnormal. Admittedly this is a rough assessment tool at best, but as a
scouting technique it directs the examiners attention to possible abnormalities and to
areas where the examiner wants to pay particular attention later on in the rest of the lung
exam. Technique: Ideally, the student should ask the patient to grab their opposite
shoulder with their hands so as to move the scapulae laterally and increase the
examinable area of the posterior lung fields.
< Must be done on skin, not over a gown or an article of clothing
< Student should place either
i. the dorsal surface of their fingers or
ii. the ulnar surface of their hands and fifth fingers or
iii. the ball of their hand (metacarpal phalangeal joints of fingers 2-5) on
patients posterior chest, beginning at the top of the chest first.
Any of these three positions helps optimize the examiners appreciation of
vibration through the bones of their hands/fingers.
< Student then asks the patient to keep repeating a phrase such as ninety-nine or
one-one-one while they examine the patient for tactile fremitus.
< If the student cannot appreciate the fremitus at first, they should ask the patient to
speak more loudly or in a deeper voice.
< The student should examine for tactile fremitus in at least three locations posteriorly
(upper, middle, and lower chest wall) and then one area laterally (remember the right
middle lobe has no posterior projection.)

18. Demonstrate the technique of percussion
< Purpose of percussion: to determine if the tissues 5-7 cm deep to/underlying the
percussed site are air filled (normal lung), fluid filled (e.g., pleural effusion), or solid
(e.g., tumor/mass).
< Technique of percussion:
Ideally, the student should ask the patient to grab their opposite shoulders with
their hands so as to move the scapulae laterally and increase the examinable
area of the lung fields.
Must be done on skin, not over a gown or an article of clothing
Student places the end of (from the DIP joint to the tip of the finger) their index
or middle finger firmly against the patients posterior chest, ideally in an
intercostal space and not over a rib.
No other part of the students hand should be resting on the patients posterior
chest. If they rest more of their finger or hand against the posterior chest, the
student dampens the percussed sound.
Using the other hands index and/or middle finger, the student quickly strikes at
the finger on the chest and withdraws the percussing finger quickly. If the
percussing finger is left on the chest, this will also dampen the percussed sound.
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Introduction to the Practice of Medicine 1

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The action of percussion works best if the percussing hands wrist is already
close to the chest wall and the act of percussing comes from flexion at the wrist.
Flexion of the percussing finger alone does not provide enough strength to create
a percussed sound. Also, if the percussing hand is far from the patients chest, it
is very difficult to accurately strike the finger on the chest.
The student should always start at the top of the lungs and should always
compare right side to left at a given level. How many areas that need to be
percussed is debatable. Bates recommends 7 different areas posteriorly and 3
anteriorly. It is probably sufficient for the student to assess the same areas by
percussion as they did by tactile fremitus upper, middle, and lower posterior
chest wall and then lateral chest wall.

19. State the five percussion notes and their characteristics

Percussion Note Intensity Pitch Duration Example of Location
Flatness: Soft High Short Thigh
Dullness: Medium Medium Medium Liver
Resonance: Loud Low Long Normal lung
Hyperresonance: Very loud Lower Longer None normally
Tympany: Loud High Gastric air bubble or
puffed-out cheek

WASH HANDS