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

  1. Classify breath sounds by their expected location and relationship to the respiratory cycle.
  2. Identify the five cardiac assessment points on the precordium.
  3. Describe appropriate use of the stethoscope's bell and diaphragm.
  4. Describe grading scales for assessment of cardiac murmurs.
  5. Describe normal heart sounds and their relationship to the cardiac cycle.
  6. Recognize extra heart sounds.
  7. Identify tests for spinal mobility.

Equipment needed:

  1. Anatomy of the Thorax

    1. Diaphragm located at 6th intercostal space anteriorly and 10th intercostal space posteriorly.

    2. Anterior Landmarks: midsternal line, midclavicular line (MCL), anterior axillary line.
    3. Posterior Landmarks: midspinal line, midscapular line, posterior axillary line
    4. Lateral landmarks: anterior axillary line, midaxillary line, posterior axillary line
    5. We describe locations on the thorax by intercostal space and the lines described above.
  2. Lungs http://www.medinfo.ufl.edu/year1/bcs/clist/resp.html  

    1. Inspection

      1. 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.
      2. 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, etc.)
      3. Respiratory rate and depth. http://www.meddean.luc.edu/lumen/MedEd/MEDICINE/pulmonar/PD/E-VENT.HTM 

    2. Palpation

      1. Ribs and spine - palpate all areas for tenderness, pain, soft areas.

      2. Bilateral chest expansion http://www.meddean.luc.edu/lumen/MedEd/MEDICINE/pulmonar/PD/PSTEP26.HTM 

      3. Tactile fremitus - place ball of hands on chest, have patient say "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 chest. http://www.medinfo.ufl.edu/year1/bcs/clist/resp.html#FREM 

    3. Percussion http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/pstep28.htm 

      1. 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.)

      2. Anterior and posterior chest http://www.meddean.luc.edu/lumen/MedEd/MEDICINE/pulmonar/PD/PSTEP28.HTM 

      3. Diaphragmatic excursion http://www.medinfo.ufl.edu/year1/bcs/clist/resp.html#AA7 

    4. Auscultation

      1. Normal breath sounds
        1. Bronchial - normally heard over trachea, expiration longer than inspiration http://www.hsc.missouri.edu/shrp/rtwww/rcweb/sounds/b_breath.wav 
        2. Vesicular - heard at periphery of lungs, expiration shorter than inspiration http://www.hsc.missouri.edu/shrp/rtwww/rcweb/sounds/normal.wav 
        3. Bronchovesicular - heard between the shoulder blades, inspiration is equal to expiration
      2. Abnormal breath sounds
        1. Crackles http://www.hsc.missouri.edu/shrp/rtwww/rcweb/sounds/crackle1.wav 
        2. Wheezes http://www.hsc.missouri.edu/shrp/rtwww/rcweb/sounds/wheeze1.wav 
        3. Pleural friction rub - grating sound like two pieces of leather rubbing together
        4. Stridor - high-pitched sound caused by partial  obstruction in larynx or trachea
        5. Grunting - low-pitched sound at the end of expiration, often a sign of respiratory distress in infants
  3. Heart
    1. Inspection - must have anterior chest exposed. Client supine.
      1. Point of maximum impulse - look across the precordium for an area of pulsation.
      2. Observe for heaves or thrusts
    2. Percussion is usually not done
    3. Palpation http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/pstep36.htm 
      1. Five points across the precordium http://www.surgeryrmh.unimelb.edu.au/examCVS/sld035.htm 
        1. Aortic area - second intercostal space, right sternal border
        2. Pulmonic area - second intercostal space, left sternal border
        3. Erb's point - third intercostal space, left sternal border
        4. Tricuspid area - fifth intercostal space, left sternal border
        5. Mitral area - fifth intercostal space, left midclavicular line
      2. Point of maximum impulse - area where pulse is felt the strongest
      3. Heaves or thrusts - sharp lifting of chest wall
      4. Thrills - vibration felt with palmar surface of hand, similar to cat's purring
    4. Auscultation
      1. 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 sounds. http://www.meddean.luc.edu./lumen/medEd/medicine/PULMONAR/PD/PSTEP39.HTM 
      2. The five precordial points http://www.medinfo.ufl.edu/year1/bcs/slides/chest/slide14.html 
      3. Each site needs to be auscultated with the bell and the diaphragm of the stethoscope.
      4. Listen to S1 and S2 at each site.
        1. Where is S1 loudest? Where is S2 loudest?
        2. Are any abnormal heart sounds heard? Where in the cardiac cycle do they occur?
        3. Time the heart sounds with the upstroke of the carotid pulse. The S2 sound occurs just before the carotid pulse is felt.
  4. Breast
    1. Inspection
      1. Inspect the breast in three positions
        1. Patient sitting with hands pressed into hips,
        2. hands over head and
        3. bending forward with breasts hanging free
      2. Compare one side to the other. Look for areas of retraction, dimpling or "orange-peel" look to skin.
    2. Palpation
      1. Positioning
        1. Place a small towel under shoulder to spread breast tissue.
        2. Have patient raise arm over head.
      2. 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.
        1. Normally you will feel breast tissue, fibrous tissue and you may feel cysts.
        2. Fibrocystic breast disease results in lumpy painful breasts, especially during the premenstrual period.  http://www.natmedsol.com/Condits/Fibcysbr.htm 
      3. Gently squeeze the nipple to express clear fluid.
    3. 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.
  5. Lymph nodes
    1. Axillary lymph nodes http://www.meddean.luc.edu/lumen/MedEd/MEDICINE/PULMONAR/IMAGES/illust/draw15.jpg 
      1. 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 palpate.
      2. 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.
    2. Supraclavicular lymph nodes
      1. Palpate the region above the clavicle. Lymph nodes are usually not present here.
    3. Infraclavicular lymph nodes
      1. Palpate the region below the clavicle. Lymph nodes are usually not present here.
  6. Thoracic Spine
    1. Inspection
      1. You must be able to see the entire back.
      2. Observe the spine from the side noting the cervical, thoracic and lumbar curves
      3. Observe the spine from the behind noting
        1. shoulder height
        2. iliac crests height
        3. skin creases
        4. distance between arm and side bilaterally
        5. determine if spine is straight from T1 to gluteal folds
        6. any obvious spinal curvature or prominent scapula
      4. Have client bend over and again determine straightness of spine and if one scapula or iliac crest is prominent
      5. 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.
    2. Palpation
      1. Palpate the spinous process with the client standing and bending over
      2. Observe for any prominent spinous processes and tenderness
    3. Range of motion
      1. Flexion - have client bend forward as far as possible
      2. Lateral flexion - while sitting, have client bend sideways as far as possible
      3. Extension - while sitting, have client bend backwards as far as possible
      4. Rotation - have client turn shoulders right and then left
    4. Scoliosis http://www.coolware.com/health/medical_reporter/scoliosis.html 
      1. Kyphosis http://ww2.med.jhu.edu/ortho/peds/kyphosis/ 
      2. Kyphoscoliosis http://radiology.uchc.edu/eAtlas/Bone/713.htm 
      3. Lordosis http://seattleinsider.adam.com/ency/article/003278.htm 
  7. Expected Findings

Key terms


Accessory muscles
Angle of Louis
Anterior axillary line
anterior-posterior diameter (AP)
Bronchial sounds
Bronchovesicular sounds
Costal angle
Costophrenic angle
Diaphragmatic excursion
Intercostal spaces
Midaxillary line (MAL)
Midclavicular line (MCL)
Midsternal line
Paroxysmal nocturnal dyspnea (PND)
Posterior axillary line (PAL)
Pleural friction rub
Scapular line, R & L
Tactile fremitus
Vetebral line
Vesicular sounds
Whispered pectoriloquy
Xyphoid process


Aortic area
Cardiac cycle
Erb's point
Heave / thrust
Mitral area
Pericardial friction rub
Point of maximum impulse (PMI)
Pulmonic area
Tricuspid area


Anterior lymph node (pectoral)
Fibrocystic breast disease
Infraclavicular lymph nodes
Lateral lymph node (brachial)
Midaxillary lymph node (central)
Nipple inversion
Peau d'orange
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