Week 4: Assessment of the Chest
Required reading: Wilson & Giddens, Chapters 17, 18
and 19 and pages 650, 687.
Objectives: By the completion of this unit, the student will be able to
- Classify breath sounds by their expected location and relationship to the
- Identify the five cardiac assessment points on the precordium.
- Describe appropriate use of the stethoscope's bell and diaphragm.
- Describe grading scales for assessment of cardiac murmurs.
- Describe normal heart sounds and their relationship to the cardiac cycle.
- Recognize extra heart sounds.
- Identify tests for spinal mobility.
- Penlight (optional)
- Scoliometer (optional)
Anatomy of the Thorax
Diaphragm located at 6th intercostal space anteriorly and 10th
intercostal space posteriorly.
- Anterior Landmarks: midsternal line, midclavicular line (MCL), anterior
- Posterior Landmarks: midspinal line, midscapular line, posterior axillary
- Lateral landmarks: anterior axillary line, midaxillary line, posterior
- We describe locations on the thorax by intercostal space and the lines
- Anterior-posterior to lateral ratio: normal adult ratio is 1:2, young
children and adults with chronic pulmonary disease have a ratio of 1:1.
- Respiratory effort: Observe intercostal, neck and abdominal muscles.
Quiet regular respirations should not involve the intercostal and neck muscles. Infants
and men use abdominal muscles for breathing more than women. If a man is not using the
abdominal muscles to breathe, suspect underlying abdominal problem (tenderness, pain,
Respiratory rate and depth. http://www.meddean.luc.edu/lumen/MedEd/MEDICINE/pulmonar/PD/E-VENT.HTM
Ribs and spine - palpate all areas for tenderness, pain,
Bilateral chest expansion http://www.meddean.luc.edu/lumen/MedEd/MEDICINE/pulmonar/PD/PSTEP26.HTM
Tactile fremitus - place ball of hands on chest, have patient
"99" as you palpate over anterior and posterior surface of chest. You should
feel vibrations through chest wall. Vibrations may diminish as you palpate the lower
Pattern of percussion for anterior http://www.surgeryrmh.unimelb.edu.au/Res/sld033.htm and posterior chest http://www.surgeryrmh.unimelb.edu.au/Res/sld034.htm (It is the same as the auscultation pattern.)
Anterior and posterior chest http://www.meddean.luc.edu/lumen/MedEd/MEDICINE/pulmonar/PD/PSTEP28.HTM
Diaphragmatic excursion http://www.medinfo.ufl.edu/year1/bcs/clist/resp.html#AA7
- Normal breath sounds
- Bronchial - normally heard over trachea, expiration longer than
- Vesicular - heard at periphery of lungs, expiration shorter than
- Bronchovesicular - heard between the shoulder blades, inspiration is equal to expiration
- Abnormal breath sounds
- Crackles http://www.hsc.missouri.edu/shrp/rtwww/rcweb/sounds/crackle1.wav
- Wheezes http://www.hsc.missouri.edu/shrp/rtwww/rcweb/sounds/wheeze1.wav
- Pleural friction rub - grating sound like two pieces of leather rubbing
- Stridor - high-pitched sound caused by partial obstruction in larynx or
- Grunting - low-pitched sound at the end of expiration, often a sign of
respiratory distress in infants
- Inspection - must have anterior chest exposed. Client supine.
- Point of maximum impulse - look across the precordium for an area of
- Observe for heaves or thrusts
- Percussion is usually not done
- Palpation http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/pstep36.htm
- Five points across the precordium http://www.surgeryrmh.unimelb.edu.au/examCVS/sld035.htm
- Aortic area - second intercostal space, right sternal border
- Pulmonic area - second intercostal space, left sternal border
- Erb's point - third intercostal space, left sternal border
- Tricuspid area - fifth intercostal space, left sternal border
- Mitral area - fifth intercostal space, left midclavicular line
- Point of maximum impulse - area where pulse is felt the strongest
- Heaves or thrusts - sharp lifting of chest wall
- Thrills - vibration felt with palmar surface of
hand, similar to cat's purring
- Auscultate the five points on the precordium - There are sounds at this
site. Also select "Abnormal" at the bottom of the screen to hear other heart
- The five precordial points http://www.medinfo.ufl.edu/year1/bcs/slides/chest/slide14.html
- Each site needs to be auscultated with the bell and the diaphragm of the
- Listen to S1 and S2 at each site.
- Where is S1 loudest? Where is S2 loudest?
- Are any abnormal heart sounds heard? Where in the cardiac cycle do they
- Time the heart sounds with the upstroke of the carotid pulse. The S2
sound occurs just before the carotid pulse is felt.
- Inspect the breast in three positions
- Patient sitting with hands pressed into hips,
- hands over head and
- bending forward with breasts hanging free
- Compare one side to the other. Look for areas of retraction, dimpling or
"orange-peel" look to skin.
- Place a small towel under shoulder to spread breast tissue.
- Have patient raise arm over head.
- Using a quadrant or concentric circular pattern palpate lightly and
deeply over entire breast surface. Make sure you include the tail of Spence in the axilla.
Palpate over the nipple area and gently squeeze the nipple to express any discharge.
- Normally you will feel breast tissue, fibrous tissue and you may feel
- Fibrocystic breast disease results in lumpy painful breasts, especially
during the premenstrual period. http://www.natmedsol.com/Condits/Fibcysbr.htm
- Gently squeeze the nipple to express clear fluid.
- Abnormal findings include any mass that is tender or attached to the
chest wall or expression of any color of fluid except clear. Expression of bloody fluid
usually indicates breast cancer.
- Lymph nodes
- Axillary lymph nodes http://www.meddean.luc.edu/lumen/MedEd/MEDICINE/PULMONAR/IMAGES/illust/draw15.jpg
- With the patient sitting, examine the lateral, medial, anterior and
posterior lymph nodes. Find the general area with the arm raised, lower the arm and
- The lateral lymph node is located toward the arm. The central lymph node
is located toward the chest. The anterior lymph node (also called the pectoral) is located
under the pectoral muscle in the axilla. The posterior lymph node is located under the
muscle at the posterior axillary line.
- Supraclavicular lymph nodes
- Palpate the region above the clavicle. Lymph nodes are usually not
- Infraclavicular lymph nodes
- Palpate the region below the clavicle. Lymph nodes are usually not
- Thoracic Spine
- You must be able to see the entire back.
- Observe the spine from the side noting the cervical, thoracic and lumbar
- Observe the spine from the behind noting
- shoulder height
- iliac crests height
- skin creases
- distance between arm and side bilaterally
- determine if spine is straight from T1 to gluteal folds
- any obvious spinal curvature or prominent scapula
- Have client bend over and again determine straightness of spine and if
one scapula or iliac crest is prominent
- You may use a scoliometer to determine degree of deformity. A scoliometer
looks like a carpenter's level and is run down the spine. The bubble will move from
midline to indicate the degree of deformity.
- Palpate the spinous process with the client standing and bending over
- Observe for any prominent spinous processes and tenderness
- Range of motion
- Flexion - have client bend forward as far as possible
- Lateral flexion - while sitting, have client bend sideways as far as
- Extension - while sitting, have client bend backwards as far as possible
- Rotation - have client turn shoulders right and then left
- Scoliosis http://www.coolware.com/health/medical_reporter/scoliosis.html
- Kyphosis http://ww2.med.jhu.edu/ortho/peds/kyphosis/
- Kyphoscoliosis http://radiology.uchc.edu/eAtlas/Bone/713.htm
- Lordosis http://seattleinsider.adam.com/ency/article/003278.htm
- Expected Findings
- Skin smooth and uniform in color. Darker in areas exposed to sun. No cyanosis.
- No lesions, nodules, or superficial venous patterns.
- thorax basically symmetrical, with an anterior-posterior diameter less than
- Subcostal angle 90 degrees, widening on inspiration.
- Respiratory rate 12 to 20 breaths per minute, regular and quiet. Inspiratory phase 1/2
as long as expiratory phase.
- Chest expansion symmetrical in onset and depth, without use of accessory muscles.
- Intercostal spaces without retraction or bulging.
- Cardiac impulse visible in 1/2 of adults.
- Breast shape convex in women and even with chest wall in men. Right and left breasts may
have different size. Skin texture smooth and contour uninterrupted. Striae may be visible
but should be present bilaterally.
- Breast tissue in women dense, firm and elastic.
- Breasts free from dimpling, edema or reddened areas.
- Areolae round or oval and comparable in size. Color can range from pink
depending on skin color and pregnancy history. Texture smooth or with sprinkling of
- Nipples same color as areolae. Nipples may either be inverted or everted, equal
bilaterally with no deviation. No retraction, bleeding, cracking, or discharge.
- Axillary and supraclavicular regions free of rash, bulging, edema or infection. Axillary
and supraclavicular lymph nodes not palpable.
Angle of Louis
Anterior axillary line
anterior-posterior diameter (AP)
Midaxillary line (MAL)
Midclavicular line (MCL)
Paroxysmal nocturnal dyspnea (PND)
Posterior axillary line (PAL)
Pleural friction rub
Scapular line, R & L
Heave / thrust
Pericardial friction rub
|Point of maximum impulse (PMI)
|Anterior lymph node (pectoral)
Fibrocystic breast disease
Infraclavicular lymph nodes
Lateral lymph node (brachial)
Midaxillary lymph node (central)
Posterior lymph node (subscapular)
Supernumerary breast / nipple
Supraclavicular lymph nodes
Tail of Spence
Review Questions: Go on-line
Take the Chest Exam (due 7/9)
Chest Mastery Demonstration may be completed after you take the exam. (due 7/9)
Thorax / Nurs
352 / Calendar