Chest and Lung Anatomy and Landmarks

Chest/Lungs

• Appropriate history-of-present-illness questions include: DOE/rest? Cough? Prod/non? Orthopnea? Wheezing? Night sweats-TB? OLDCARTS: smoker? CHF? URI?
• During chest inspection, the lateral diameter generally exceeds the anterior-posterior (AP) diameter.

Thoracic landmarks

• Key landmarks include:

  • Nipples
  • Manubriosternal junction (angle of Louis): Visible and palpable angulation of the sternum; the point at which the second rib articulates with the sternum
  • Suprasternal notch: A depression, easily palpable and most often visible at the base of the ventral aspect of the neck, superior to the manubriosternal junction.
  • Costal angle: The angle formed by the costal margins at the sternum, usually no more than 90 degrees, with the ribs inserted at approximately 45-degree angles.
  • Vertebra prominens: The spinous process of C7, more readily seen and felt with the patient's head bent forward. If two prominences are felt, the upper is that of the spinous process of C7, and the lower is that of T1.
  • Clavicles

• Assess the rate and quality of respirations by inspection, noting: Respiratory rate, pattern of breathing, the use of accessory muscles, pursed lip breathing, tripod positioning, and signs of tachypnea or shallow breathing

• Assess peripheral areas for clubbing, cyanosis, and nasal flaring.

• Palpate the chest wall for tenderness and deformities, such as pectus excavatum, and assess for crepitus.

• Assess for tracheal deviation, which may indicate a collapsed lung; Oliver's sign can also be assessed.

• Assess for tactile fremitus by asking the patient to say "99" or "Mickey Mouse" while palpating the chest with the palmar surfaces of the fingers or the ulnar aspects of the hand for comparison, palpate both sides simultaneously and symmetrically so that there is no mistaking the vibration differences.

• Decreased or absent fremitus may indicate excess air, such as in emphysema, pleural effusion, or bronchial obstruction.

• Increased fremitus may indicate fluid, such as in lung consolidation or heavy nonobstructive bronchial secretions

• Evaluate thoracic expansion during respiration by standing behind the patient and placing your thumbs along the spinal processes at the level of the tenth rib, with palms lightly in contact with the posterolateral surfaces.

• Watch your thumbs diverge during quiet, deep breathing; asymmetry may indicate a problem on one or both sides

• Patients with COPD may not demonstrate thoracic expansion due to barrel chest

• Percuss the chest to assess underlying structures.

• Resonance is the expected sound heard over all areas of the lungs.

• Hyperresonance may indicate emphysema, pneumothorax, or asthma. Dullness or flatness may indicate pneumonia, atelectasis, or pleural effusion.

• Measure diaphragmatic excursion, the movement of the thoracic diaphragm during inhalation and exhalation.

• Have the patient take a deep breath and hold it, percussing along the scapular line to locate the lower border (change in note from resonance to dullness)

• Mark the point, allow the patient to breathe, and repeat on the other side.

• Measure and record the distance in centimeters between the marks (usually 3-5 cm).

• The diaphragm is usually higher on the right due to the liver, and descent may be limited by pulmonary, abdominal, or superficial pain processes.

• Three types of normal breath sounds:

  • Vesicular: Heard over most lung fields; low pitch, soft and short expirations; more prominent in thin people or children, diminished in overweight or very muscular patients
  • Bronchovesicular: Heard over the main bronchus area and upper right posterior lung field; medium pitch; expiration equals inspiration
  • Bronchial/Tracheal: Heard only over the trachea; high pitch, loud and long expirations, sometimes a bit longer than inspiration

• Abnormal breath sounds include:

  • Rhonchi: coarse, low-pitched; may clear with cough
  • Wheeze: whistling, high-pitched bronchus
  • Bronchial: coarse, loud; heard with consolidation
  • Rub: scratchy, high-pitched
  • Crackles: fine crackling, high-pitched

• Crackles may indicate:

  • Fine crackles: high-pitched, discrete, discontinuous crackling at the end of inspiration; not cleared by cough
  • Medium crackles: lower, more moist sound during midstage of inspiration; not cleared by cough
  • Coarse crackles: loud, bubbly noise during inspiration; not cleared by cough

• Rhonchi (sonorous wheeze): loud, low, coarse sounds like a snore, often heard continuously during inspiration or expiration; coughing may clear sound (usually mucus accumulation in the trachea or large bronchi).

• Wheeze (sibilant wheeze): musical noise often heard continuously, usually louder during expiration.

• Pleural friction rub: dry, rubbing, or grating sound caused by inflammation of pleural surfaces, loudest over the lower lateral anterior surface.

• Vocal resonance characteristics:

  • Bronchophony: greater clarity and increased loudness of spoken sounds
  • Whispered pectoriloquy: extreme bronchophony where even a whisper can be heard clearly
  • Egophony: increased intensity of the spoken voice with a nasal quality (e.g., "e" to "a")

• Vocal resonance changes may be present in conditions that consolidate lung tissue or diminished where there is loss of tissue within the respiratory tree (e.g., with the barrel chest of emphysema)

Head/Neck

• Head and face inspection: Transilluminate skull in infants, assess for trigeminal neuralgia (CN 5) and Bell's palsy (CN 7).

• Palpate the skull for fontanel closure/Macewen sign, tenderness, lumps, or depressions. Assess the temporomandibular joint (TMJ) and percuss the masseter muscle for Chvostek sign (hypocalcemia).

• Auscultate temporal region for bruits (cardiac anomaly, aneurysm, or temporal arteritis).

• Inspect the neck for symmetry, enlarged lymph nodes, alignment of the trachea, webbing, skin folds or masses. Structures to check are the trachea, jugular veins, carotids, esophagus, and thyroid gland.

• Evaluate range of motion and muscle strength of the neck, testing CN XI (accessory nerve). Monitor stiff neck, pain, or limitation of movement.

• Palpate the five areas of the neck, noting anatomical landmarks (hyoid bone, cartilage), lymph nodes, paravertebral muscles, and spinous processes.

• Inspect, palpate, and auscultate the thyroid gland.

• Palpate thyroid gland for goiter, nodules, size, shape, consistency.

Lymph

• When assessing a chief complaint of a lymph node issue, ask about immune function/recent illness, chemotherapy or medications known to affect the lymph nodes. Check for enlarged lymph nodes or red streaks, and use OLDCARTS to characterize symptoms.

• Inspect and palpate lymph nodes, noting edema, erythema/red streaks, tenderness, size (fixed or movable), consistency (hard/firm or soft), discreteness or matting, and warmth.

• Palpate using fingertips, noting small, soft/firm, non-tender, and freely movable nodes (normal finding). Shotty nodes are small, non-tender nodes that feel like BBs under the skin

• Abnormal findings include fluctuant (wave-like motion), matted nodes (connected and move as a unit), enlarged nodes.

• When assessing the features of enlarged lymph nodes in any region, they should be characterized according to location, size, shape, consistency (fluctuant, soft, firm, hard), tenderness, mobility or fixation to surrounding tissues, and discreteness.

• A hard, fixed, painless node suggests a malignant process and tender nodes suggests an inflammatory process.

• Nodes should not pulsate, and a palpable supraclavicular node on the left (Virchow node) suggests thoracic or abdominal malignancy. Slow nodal enlargement suggests a benign process, rapid enlargement without signs of inflammation suggests malignancy.

• The six areas of the head and their associated lymph nodes: pre-auricle, post-auricle, occipital, tonsillar, submandibular, submental

• The four areas of the neck and their associated lymph nodes: superficial cervical, posterior cervical, deep cervical chain, supraclavicular

• To examine axillary lymph nodes, support the patient's forearm with your contralateral arm and bring the palm of your examining hand flat into the axilla, they can rest their arm for you to examine also.

• Other clusters of accessible lymph nodes include axillary, epitrochlear, superficial superior inguinal, and superficial inferior inguinal.

Overview of chest and lung anatomy, including key landmarks for physical examination. Covers important questions for history of present illness and thoracic inspection. Focuses on landmarks such as the nipples, manubriosternal junction, and costal angle.