Identify on skeleton bony landmarks of the thoracic region including thoracic vertebrae, sternum, ribs.
C7 “Vertebra Prominens” = first palpable spinous process
T2 = Superior angle of the scapula
T3 = Root of the spine of the scapula
T7 = Inferior angle of scapula
T12 = Mid-point between the inferior angle of the scapula and top of iliac bone along the scapular line
L4 = highest point of the iliac crest
Ribs: 1-7=true, 8-10=false, 11,12=floating
Identify surface markings of bony landmarks –suprasternal notch, sternal angle, xiphisternum, costal
margins, and thoracic vertebral levels.
T2 – Superior angle of scapula
T2/3 - Jugular Notch
T3 – Medial end of scapula
T4/5 - Sternal angle / manubriosternal joint. 2nd costal cartilage is right next to this
T7 – Inferior angle of scapula
T5-8 - body of sternum
T8/9 – Xiphisternal joint
T9 – Xiphisternum
Describe and demonstrate the surface marking and palpation of the trachea at the suprasternal notch
- Palpation above the jugular notch
- Should be symmetrical, no deviation
Demonstrate how you would investigate symmetrical inflation of the lung and describe the anatomical
basis.
- Place hands around lower part of chest (R5/6) (as if squeezing together), with thumbs touching at the midline.
- Ask patient to take a big breath in and out and look at your thumbs – there should be equal expansion on both sides of the midline.
- Normal expansion is about 5cm
Observe and describe the breathing pattern and the breathing rate.
- Ask to take patient’s pulse. Look at chest. Want to see symmetrical rise.
- Normal rate – 12-20/min. Below = bradypnoea, above = tachypnoea
- Pattern – Regular, obstructive (prolonged expiration), Kussmaul’s (fast and deep), Cheyne-Stokes (Increasing in frequency and depth, to a peak, then decreasing in freq. and depth to a period of apnoea.
Demonstrate percussion of upper/lower/middle lobe(s) of right/left lungs.
- Hollow, drum-like sound over air-filled spaces (i.e. lung)
- Dull sound over sold organs (heart) or liquids
- Percuss the front as they lie 45°, percuss the back when they lean forward
- Ask the patient to cross their arms when listening to the back – this moves the scapula out of the way (protraction).
- Press middle finger into ICS, tap distal phalangeal joint (clavicle – tap directly).
- Compare right and left
Superior lobe
- Anterior: Clavicle (medial third), 2nd ICS MCL, 4th ICS MCL (LHS only)
- Posterior: 1st ICS medial sternal border (MSB), 3rd ICS MSB
Middle lobe
- Anterior: 4th ICS MCL RHS, 6th ICSL MAL RHS (Useful in F)
Inferior Lobe
- Anterior: 6th ICS MCL, 6th ICS MAL
- Posterior: 7th ICS Scapular line
Describe/ demonstrate where you would auscultate upper/middle/lower lobe(s) of right/left lungs
- All areas with diaphragm (except 1 and 2 – use the bell).
- Bronchial breathing – over trachea, manubrium and sternal angle (high pitched)
- Vesicular breathing – everywhere else
- Ask pt. to breathe through mouth
- Listen for equal L+R, S, M+L.
Superior lobe
- Anterior: Clavicle (medial third), 2nd ICS MCL, 4th ICS MCL (LHS only)
- Posterior: 1st ICS medial sternal border (MSB), 3rd ICS MSB
Middle lobe
- Anterior: 4th ICS MCL RHS, 6th ICSL MAL RHS (Useful in F)
Inferior Lobe
- Anterior: 6th ICS MCL, 6th ICS MAL
- Posterior: 7th ICS Scapular line
Listen for added sounds (wheeze, crackles, plural rub)
Describe & demonstrate the surface markings of upper, middle, lower lobe of right/left lungs.
Superior Lobe (RHS):
- Apex at 1inch above medial 3rd of clavicle
- Over sternoclavicular joint
- Down the right sternal border (RSB) to R4, follows R4 round to T3/4
- Lateral to spine to apex
Superior Lobe (LHS):
- Apex at 1inch above medial 3rd of clavicle
- Over sternoclavicular joint
- Down the right sternal border (RSB) to R6 (Deviation at R4-6 2-3cm)
- Round to T3/4
- Lateral to spine to apex
Middle Lobe (RHS):
- RSB R4
- Follows RSB to R6
- Follows R6 to MCL
- Up to R4 MAL
Inferior Lobe (RHS):
- R6 MCL to R4 MAL
- To T3/4
- Down lateral to spine to T10
- Round to R6 MCL
Inferior lobe (LHS)
- 6th rib MCL, 8th rib MAL, 10th rib posteriorly to spine
- Superior border of the inferior lobe follows 6th rib MCL to 4th rib MAL to 3/4th vertebra
Describe and demonstrate the surface markings of the oblique and horizontal fissures of right/left lung.
Oblique Fissure (Both): - R6 MCL to R4 MAL to spine of T3 posteriorly (usually follows the medial border of scapula when the arm is raised above the head)
Horizontal Fissure (RHS):
- RSB CC4, follows R4 to MAL to join oblique fissure
- Just above the nipple in males
Describe and demonstrate the surface marking of the inferior margin of parietal pleura of right/left lung.
- Apex at 1 inch above medial 3rd of clavicle
- Over sternoclavicular joint
- Down sternal border to xiphisternal joint - just right/left of anterior median line at centre of sternal angle, level of 4th CC and level of 6th CC
- R8 at MCL
- R10 at MAL
- R12/T12 at medial scapular border (lateral margin of erector spinae muscles)
- Transverse process of L1 vertebra to T1 transverse process
- (LHS, deviation 1cm from R4-6)
Describe and demonstrate the surface marking of the visceral pleura of right/left lung.
- Apex at 1 inch above medial 3rd of clavicle
- Over sternoclavicular joint
- Down sternal border to xiphisternal joint - just right/left of anterior median line at centre of sternal angle, level of 4th CC and level of 6th CC
- R6 at MCL
- R8 at MAL
- R10/T10 at medial scapular border
- Up lateral to spine to T1
- (Left lung, deviation 2-3cm from R4-6)
Describe and demonstrate the triangle of safety for insertion of a chest drain.
Why is one performed?
- Ant: Anterior axillary fold of pectoralis major
- Post: Posterior axillary fold of latissimus dorsi
- Inf.: 5th ICS at MAL.
- Sup: Below apex of axilla (R2)
- Placement – above superior border of inferior rib to avoid the intercostal nerve, pointing upwards and medially (Needle point 2nd, 3rd, 4th, 5th ICS in MAL)
- Why do one? – Pneumothorax, pleural effusion, haemothorax, post-op
- For apical pneumothoraces, 2nd ICS MCL used
Describe & demonstrate the surface marking of mediastinal pleura of right & left lung on the anterior
chest wall
- R sternoclavicular joint over RSB to R6 (becomes diaphragmatic pleura)
- Break at sternal angle for lung root
- L sternoclavicular joint over RSB to R6 (becomes diaphragmatic pleura)
- Indentation from R4-6 2-3cm
Demonstrate the surface marking of upper/right/inferior/left borders of the heart.
- Upper – CC3 1cm from RSB to 2.5cm left of LSB at CC2
- Right – Lat to RSB at CC3 to RSB 6CC (1cm form sternal border)
- Inferior – RSB CC6 to 5th ICS MCL
- Left – 2nd CC 2.5cm to LSB to 5th ICS at MCL
Demonstrate where you would auscultate for aortic/pulmonary/mitral/tricuspid valves using a
stethoscope.
Aortic – RSB 2nd ICS (located at 3rd ICS)
Pulmonary – LSB 2nd ICS (located at 3rd CC)
Tricuspid – LSB 5th ICS (located at 4th ICS)
Mitral – MCL 5th ICS (apex beat - actually located at 4th CC)
A place to meet at 22:55
Examine the radial/ulnar/brachial (2 sites)/carotid pulse and describe them (rate and rhythm).
- Radial – Distal end of radius
- Ulnar – between ulna and radius
- Brachial – along middle 3rd of humerus, medial bicipital groove behind medial border of biceps. AND cubital fossa, medial side of tendon of biceps on fully extended elbow
- Carotid – Between anterior border of SCM and thyroid cartilage
Rate – normal = 60-100bpm
Rhythm – regular/irregular
Describe the surface marking of the apex beat of the heart and demonstrate palpation.
- Count to R5 (LHS), follow to MAL, place finger in ICS and follow round to MCL
- Jogging on the spot makes it easier to find
Demonstrate the sites of routine venepuncture
Median cubital vein/ antebrachial vein
Describe and demonstrate the surface marking of the arch of the aorta
List the branches
- RSB CC2, arches to midway between jugular notch and sternal angle, down to LSB CC2
- Branches – Brachiocephalic trunk, left common carotid artery, left subclavian artery
Describe and demonstrate the surface markings of the internal jugular vein and common carotid artery
- Common carotid artery – Turn head to side, so SCM visible. From ear lobe to sternoclavicular joint, up trachea then up anterior border of SCM
- Internal Jugular vein – Just lateral to -upper part of sternal end of clavicle, to midway between tip of mastoid process and angle of mandible. Clavicle to upper border of thyroid cartilage. Joins with SCV at sternoclavicular joint to form brachiocephalic vein. (lateral to the CCA)
- Central line – Internal jugular vein between the two heads of SCM heads. Then subclavian, then femoral vein
List characteristics of typical vertebrae in each region
- The seven cervical vertebrae between the thorax and skull are characterized mainly by their small size and the presence of a foramen in each transverse process
- The 12 thoracic vertebrae are characterized by their articulated ribs although all vertebrae have rib elements, these elements are small and are incorporated into the transverse processes in regions other than the thorax; but in the thorax, the ribs are separate bones and articulate via synovial joints with the vertebral bodies and transverse processes of the associated vertebrae.
- Inferior to the thoracic vertebrae are five lumbar vertebrae, which form the skeletal support for the posterior abdominal wall and are characterized by their large size
- Next are five sacral vertebrae fused into one single bone called the sacrum, which articulates on each side with a pelvic bone and is a component of the pelvic wall.
- Inferior to the sacrum is a variable number, usually four, of coccygeal vertebrae, which fuse into a single small triangular bone called the coccyx.
