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SURFACE MARKINGS OF THORACIC STRUCTURES
PRESENTER--DR.P.RAVINDER RAO MD (HOM) PG-
XIV BATCH
MODERATER--DR.A.V.RAJESHWER RAO
M Sc (Psychology), MD (HOM)
P.G. GUIDE & ASST.PROFESSOR
DEPARTMENT OF SURGERY
PLAN OF STUDY Introduction Need for study Land marks of thorax Surface markings of thoracic structures Importance of thoracic surface markings Conclusion Bibliography
Introduction
Surface anatomy: study of internal body structures as they relate to the overlying skin
Need for study As medical personnel, we will be
examining the chest to detect evidence of disease.
Our examination consists of inspection, palpation, percussion, and auscultation.
To make these examinations, the physician must be familiar with the normal structure of the thorax and must have a mental image of the normal position of the lungs and heart in relation to identifiable surface landmarks.
Land marks of thorax
The suprasternal notch
It is situated in the midline between the medial ends of the clavicles and above the upper edge of the manubrium.
The angle of Louis (sternal angle)
It is formed by the joint between the manubrium and body of the sternum.
It is an important landmark as the 2nd costal cartilages articulate on either side and by following this line onto the 2nd rib, further ribs and intercostal spaces can be identified.
The sternal angle corresponds to a horizontal point level with the intervertebral disc between T4 and T5.
Carina of trachea is at this level. Mediastinum is divided into superior and
inferior at this level.
The costal margin It is formed by the lower borders of the cartilages of the 7th, 8th, 9th and 10th ribs and the ends of the 11th and 12th ribs.
The xiphisternal joint
It is formed by the joint between the body of
thesternum and xiphisternum
Vertebra prominence The first palpable spinous process
is that of C7 . (vertebra prominence).
C1–6 vertebrae are covered by the thick ligamentum nuchae.
The spinous processes of the thoracic vertebrae can be palpated and counted
in the midline posteriorly.
The scapula
Is flat and triangular in shape and is located on the upper part of the posterior surface of the thorax. The superior angle lies opposite the spine of the second thoracic vertebra. The spine of the scapula is subcutaneous, and the root of the spine lies on a level with the spine of the third thoracic vertebra. The inferior angle lies on a level with the spine of the seventh thoracic vertebra. In slim subjects the superior angle, inferior angle, spine and medial (vertebral) border of the scapula are easily palpable.
RIBSAnteriorly ribs are counted down starting from 2nd rib. There are 12 ribs and 11 interspaces. You can also count up from 12th rib. Inferior angle of scapula sits on 7th rib posteriorly.
Lines of orientation
These are imaginary vertical lines used to
describe locations on the chest wall. These include:
Midsternal Line: A vertical line down the middle of sternum
Parasternal Line: A vertical line along lateral edge of sternum
Mid-Clavicular Line: A vertical line from middle of clavicle
Anterior Axillary Line: A vertical line along anterior axillary fold
Mid-Axillary Line: A vertical line at mid point between anterior and posterior axillary line.
Posterior Axillary Line: Along post axillary fold
Scapular Line: Inferior angle of scapula
Vertebral line: Over spinous processes in the midline
Anterior imaginary lines and landmarks
epigastric angle
Infraclavicular fossa
Mid sternal line
Suprasternal fossa Supraclavicular fossa
Para sternal line
Midclavicular line
Lateral imaginary lines
Anterior axillary line
Midaxillary line
Posterior axillary line
Posterior imaginary lines and landmarks
Scapular line
Posterior midline
Infrascapular region
Interscapular region
Suprascapular region
SPACESAnteriorly there are supra clavicular, infraclavicular, precardiac and Traube's space. Posteriorly we have interscapular, supra, and infra scapular spaces.
Infraclavicular: Space below clavicle Supraclavicular: Space above clavicle Precardiac: Space in front of heart Traube's: Space overlying stomach Interscapular: Space between scapula Suprascapular: Space above scapula Infrascapular: Space below the scapula
STRUCTURES IN THORAX
It includes the Breast externally, and internally on either sides Pleural sacs filled with Lungs, and in the middle Mediastinum.
Heart, and Great vessels present in the middle mediastinum
Superior : trachea, thymus, brachiocephalic vein, aortic arch, esophagus thoracic duct
Middle: heart, ascending aorta, pulmonary trunk and veins, phrenic nerves
Posterior: esopahagus vagus nerves, descending aorta, thoracic duct, sympathetic trunks
Anterior: fat, connective tissue, thymus in child
THE SURFACE MARKINGS OF THORACIC STRUCTURES
MAMMARY GLAND
The mammary gland lies in the superficial fascia covering the anterior chest wall.
In the young adult female, it overlies the second to the sixth ribs and their costal cartilages and extends from the lateral margin of the sternum to the Midaxillary line.
Its upper lateral edge extends around the lower border of the pectoralis major and enters the axilla.
The position of the nipple is variable in the female but in the male it is usually in the 4th intercostal space in the midclavicular line.
TRACHEA The trachea extends from the lower border of
the cricoid cartilage (opposite the body of the 6th cervical vertebra) in the neck to the level of the sternal angle in the thorax.
It commences in the midline and ends just to the right of the midline by dividing into the right and left principal bronchi.
At the root of the neck it may be palpated in the midline in the suprasternal notch.
The bifurcation occurs at the level of the sternal angle (T4-T5).
The pleura The cervical pleura bulges upward into the
neck and has a surface marking identical to that of the apex of the lung.
A curved line may be drawn, convex upward, from the sternoclavicular joint to a point 1 in. (2.5 cm) above the junction of the medial and intermediate thirds of the clavicle.
The anterior border of the right pleura runs down behind the sternoclavicular joint, almost reaching the midline behind the sternal angle. It then continues downward until it reaches the xiphisternal joint.
The pleura(Conti.) The anterior border of the left pleura
has a similar course, but at the level of the fourth costal cartilage it deviates laterally and extends to the lateral margin of the sternum to form the cardiac notch. (Note that the pleural cardiac notch is not as large as the cardiac notch of the lung-forms cardiac recess) It then turns sharply downward to the xiphisternal joint.
The pleura(Conti.) The lower border of the pleura on both sides
follows a curved line, which crosses the 8th rib in the midclavicular line and the 10th rib in the Midaxillary line, and reaches the 12th rib adjacent to the vertebral column that is, at the lateral border of the erector spinae muscle.
Note that the lower margins of the lungs cross the 6th, 8th, and 10th ribs.
The distance between the two borders corresponds to the costodiaphragmatic recess.
The lungs The apex of the lung projects
into the neck. It can be mapped out on the anterior surface of the body by drawing a curved line, convex upward, from the sternoclavicular joint to a point 1 in. (2.5 cm) above the junction of the medial and intermediate thirds of the clavicle.
The lungs (Conti..) The anterior border of the right lung begins
behind the sternoclavicular joint and runs downward, almost reaching the midline behind the sternal angle. It then continues downward until it reaches the xiphisternal joint. The anterior border of the left lung has a similar course, but at the level of the fourth costal cartilage it deviates laterally and extends for a variable distance beyond the lateral margin of the sternum to form the cardiac notch. This notch is produced by the heart displacing the lung to the left. The anterior border then turns sharply downward to the level of the xiphisternal joint.
The lungs (Conti..) The lower border of the lung in mid
inspiration follows a curving line, which crosses the 6th rib in the midclavicular line and the 8th rib in the Midaxillary line, and reaches the 10th rib adjacent to the vertebral column posteriorly. It is important to understand that the level of the inferior border of the lung changes during inspiration and expiration.
The posterior border of the lung extends downward from the spinous process of the 7th cervical vertebra to the level of the 10th thoracic vertebra and lies about 1.5 in. (4 cm) from the midline.
The lungs (Conti..) The oblique fissure of the lung can
be indicated on the surface by a line drawn from the root of the spine of the scapula (level of spine of T3) obliquely downward, laterally and anteriorly, following the course of the sixth rib to the sixth costochondral junction.
In the left lung the upper lobe lies above and anterior to this line; the lower lobe lies below and posterior to it.
The lungs (Conti..) In the right lung is an additional fissure, The horizontal fissure, which may
be represented by a line drawn horizontally along the fourth costal cartilage to meet the oblique fissure in the Midaxillary line.
Above the horizontal fissure lies the upper lobe and below it lies the middle lobe; below and posterior to the oblique fissure lies the lower lobe.
The lungs (Conti..) The lungs sit within the pleural sacs and
follow the contours of the sacs with two important deviations:
1) The left lung has a cardiac notch around the ventricles of the heart. This is a region where the lung tissue is absent.
2) Also the lungs do not project into the lowest aspects of the pleural sacs. These regions are referred to as the pleural reflections or recesses.
Lung surface markings REMEMBER: 2,4,6,8,10 Lungs
Each lung extends 3cm above the clavicle (apex)
Anterior borders of lungs are closest at the sternal angle – 2nd costal cartilage (cc)
Both reach to 4thcc Left:
Moves away from the midline at the 4th cc
Right: Moves away from the midline at
the 6th cc Both cross the midclavicular
line at the 8th cc Both cross the midaxillary line
at the 10th cc
Note about pleura: They have the same surface markings as the lungs but reach further down to the 12th ccREMEMBER: 2,4,6,8,10,12 Pleura
Anterior view of lobes
Right lateral view of lobes
Left lateral view of lobes
Posterior view of lobes
THE HEART
For practical purposes, the heart may be considered to have an apex and four borders.
The apex, formed by the left ventricle, corresponds to the apex beat and is found in the fifth left intercostal space 3.5 in. (9 cm) from the midline, just medial to midclavicular line.
The superior border, formed by the roots of the great blood vessels, extends from a point on the second left costal cartilage (remember sternal angle) 0.5 in. (1.3 cm) from the edge of the sternum to a point on the third right costal cartilage 0.5 in. (1.3 cm) from the edge of the sternum.
THE HEART (Conti..)
The right border, formed by the right atrium, extends from a point on the third right costal cartilage 0.5 in. (1.3 cm) from the edge of the sternum downward to a point on the sixth right costal cartilage 0.5 in. (1.3 cm) from the edge of the sternum. Almost in line with the SVC and IVC.
The left border, formed by the left ventricle and left auricle, extends from a point on the second left costal cartilage 0.5 in. (1.3 cm) from the edge of the sternum to the apex beat of the heart.
The inferior border, formed by the right ventricle and the apical part of the left ventricle, extends from the sixth right costal cartilage 0.5 in. (1.3 cm) from the sternum to the apex beat.
THE HEART (Conti..)
The coronary sulcus can be indicated by a line from the third left, to the sixth right, sternocostal joint.
The anterior longitudinal sulcus is a finger’s breadth to the right of the left margin of the heart.
Chapter 18, Cardiovascular System 43
Heart Anatomy
Figure 18.1
Size, Shape, Location of the Heart Size of a closed
fist Shape
Apex: Blunt rounded point of cone
Base: Flat part at opposite of end of cone
Located in thoracic cavity in middle mediastinum
Approximate location of the heart projected to the surface
Landmarks Superior R point: Is at
the superior border of the R 3rd costal cartilage
Superior L point: Is located at the inferior border of the L 2nd costal cartilage
Inferior L point: (the apex) is located at of the heart in the L 5th intercostal space
Inferior R point: Is located at the superior border of the 6th R costal cartilage
Vessels returning blood to the heart include:1. Superior and inferior venae cavae2. Right and left pulmonary veins
Vessels conveying blood away from the heart include:
1. Pulmonary trunk, which splits into right and left pulmonary arteries
2. Ascending aorta (three branches) –a. Brachiocephalicb. Left common carotidc. Subclavian arteries
External Heart: Major Vessels of the Heart (Anterior View)
Arteries – right and left coronary (in atrioventricular groove), marginal, circumflex, and anterior interventricular arteries
Veins – small cardiac, anterior cardiac, and great cardiac veins
External Heart: Vessels that Supply/Drain the Heart (Anterior
View)
Chapter 18, Cardiovascular System 48
External Heart: Anterior View
Figure 18.4b
Vessels returning blood to the heart include:1. Right and left pulmonary veins2. Superior and inferior venae cavae
Vessels conveying blood away from the heart include:1. Aorta2. Right and left pulmonary arteries
External Heart: Major Vessels of the Heart (Posterior View)
Arteries – right coronary artery (in atrioventricular groove) and the posterior interventricular artery (in interventricular groove)
Veins – great cardiac vein, posterior vein to left ventricle, coronary sinus, and middle cardiac vein
External Heart: Vessels that Supply/Drain the Heart (Posterior
View)
Chapter 18, Cardiovascular System 51
External Heart: Posterior View
Figure 18.4d
Chapter 18, Cardiovascular System 52
Gross Anatomy of Heart: Frontal Section
Figure 18.4e
Heart Valves Heart valves ensure unidirectional
blood flow through the heart Atrioventricular (AV) valves lie
between the atria and the ventriclesAV valves prevent backflow into the
atria when ventricles contractR-AV valve = tricuspid valveL-AV valve = bicuspid or mitral valve
Chordae tendineae anchor AV valves to papillary muscles
Heart Valves (Conti..) Semilunar valves prevent backflow
of blood into the ventricles Aortic semilunar valve lies
between the left ventricle and the aorta
Pulmonary semilunar valve lies between the right ventricle and pulmonary
Have no chordae tendinae attachments
Heart Valves (Conti..) Draw a line from the 3rd left costal cartilage to
the 6th right costal cartilage just lateral to the sternum. Write the letters P A B T from the top of this line to the bottom of the line, evenly spaced.
This represents the position of the pulmonary (P), aortic (A), bicuspid or mitral (B), and tricuspid (T) valves. While the above procedure allows you to map the anatomical position of the heart valves, this position is not the best place to hear the heart sounds.
Heart Valves (Conti..) The pulmonary orifice- is situated in the upper
angle of the third left sternocostal articulation. The aortic orifice -is a little below and medial to
this, close to the articulation. The left atrioventricular opening -is opposite
the fourth costal cartilage, and rather to the left of the midsternal line.
The right atrioventricular opening-is a little lower, opposite the fourth intercostalspace of the right side.
The lines indicating the atrioventricular openings are slightly below and parallel to the line of the coronary sulcus.
Heart Valves (Conti..) The best place to listen for the valves is
as follows: Aortic - 2nd right intercostal space just
lateral to sternum. Pulmonary - 2nd left intercostal space
just lateral to sternum. Bicuspid - at apex beat (5th inter costal
space just medial to midclavicular line). Tricuspid - Just to the left of the
xiphisternal joint.
Heart Sounds Heart sounds (lub-dup) are
associated with closing of heart valves.First sound occurs as AV valves close and signifies beginning of systole (contraction).
Second sound occurs when SL valves close at the beginning of ventricular diastole (relaxation).
Location of Heart Valves
Heart Valves Atrioventricular
TricuspidBicuspid or
mitral Semilunar
AorticPulmonary
Prevent blood from flowing back
63
Heart Valves
Figure 18.8a, b
Heart Valves
Mitral Valve Prolepses
Artificial Heart
PULMONARY TRUNK First mark the pulmonary valve by a
horizontal line 2.5 cm long, mainly along the upper border of the left 3rd costal cartilage and partly over the adjoining part of the sternum.
Then mark the pulmonary trunk by two parallel lines 2.5 cm apart from the pulmonary orifice upwards to the left 2nd costal cartilage.
ASCENDING AORTA
First mark the aortic orifice by a slightly oblique line 2.5 cm long running downwards and to the right over the left half of the sternum beginning at the level of the lower border of the left 3rd costal cartilage.
Then mark the ascending aorta by two parallel lines 2.5 cm apart from the aortic orifice upwards to the right half of the sternal angle.
ARCH OF AORTA
Arch of aorta lies behind the lower half of the manubrium sterni. Its upper convex border is marked by a line which begins at the right end of the sternal angle, arches upwards and to the left through the centre of the manubrium, and ends at the sternal end of the left 2nd costal cartilage.
DESCENDING THORACIC AORTA
Descending thoracic aorta is marked by two parallel lines 2.5 cm apart, which begin at the sternal end of the left 2nd costal cartilage, pass downwards and medially, and end in the median plane 2.5 cm above the transpyloric plane.
SUPPPERIOR VENA CAVA
Superior vena cava is marked by two parallel lines 2 cm apart, drawn from the lower border of the right first costal cartilage to the upper border of the 3rd right costal cartilage, overlapping the right margin of the sternum.
BRACHIOCEPHALIC VEINS
Formed by the confluence of the internal jugular and subclavian veins.
This occurs posterior to the sternoclavicular joints.
DIAPHRAGM
The central tendon of the diaphragm lies directly behind the xiphisternal joint.
In mid-inspiration the highest part of the right dome reaches as far as the upper border of the 5th rib in the mid-clavicular line.
The left dome reaches only the lower border of the 5th rib.
IMPORTANCE OF THORACIC SURFACE
MARKINGS
CHEST-INSPECTION
Chest asymmetry
Kyphoscoliosis Larger hemi thorax :
(Pneumothorax, Pleural effusion)
Smaller hemi thorax: (Atelectasis, Pleural fibrosis, Agenesis of Lung)
Increased pleural negative pressure.
Unilateral (airway obstruction) or bilateral (COPD, Asthma).
Intercostal and supraclavicular fossa retraction.
Downward movement of trachea with quiet inspiration.
Respiratory Rate and Pattern of Breathing
The patient should not be aware that you are counting his respiratory rate. Count the respiratory rate while pretending to take the patient's pulse.
Note the rate, pattern and comfort of respiration.
Respiratory Rate and Pattern of Breathing
Normal
Resting rate is between 10-14 per minute, regular with no apparent discomfort..
Chest wall and abdomen expand during inspiration and is symmetrical.
Abdominal component of expansion is dominant in men and thoracic component in women.
Periodic deep breathing (Sighs) less than 5 per minute.
Abnormal Finding
Minor changes in rate and rhythm of respiration occur due to anxiety and while it may represent an abnormality, it may not be significant
Rate Rate below 10/min: Bradypnea:
(Narcotics, raised intracranial tension, myxedema)
Rate above 20/min: Tachypnea: (Interstitial, vascular and multitude of diseases, anxiety
Pattern Periodic breathing. Cyclical increase
and decrease in depth of respiration: Cheyne-stokes breathing: (CHF, Cerebrovascular insufficiency)
Slow deep breathing: Kussmaul: (Ketoacidosis)
Totally irregular with no pattern:Biot's breathing: (CNS injury)
Periodic deep breathing: Sighs: (Anxiety state)
Instead of simultaneous chest and abdominal expansion with inspiration abdomen retracts while chest expands: Abdominal paradox: (Diaphragmatic paralysis)
Pattern(Conti..)
On the side of unstable chest wall hemithorax retracts while the normal side expands with inspiration: Thoracic paradox: (Flail chest)
With lips pursed patient controls expiration slowly: Pursed lip breathing: (Obstructive lung disease)
No abdominal component : ( Acute abdomen)
No thoracic component: (Pleurisy, Chest wall pain, Ankylosing spondylitis)
Discomfort Labored breathing: (Heart and Lung
diseases) Unable to assume supine position because
of worsening shortness of breath: Orthopnea: (CHF, Diaphragmatic paralysis, SVC syndrome, Anterior mediastinal mass)
Unable to erect position because of worsening shortness of breath, more comfortable in supine position : Platypnea: (Pulmonary spiders in cirrhotic)
Symmetry of Hemi thorax
Both sides are equal in size and asymmetry is abnormal. Unilateral lung or pleural disease alters negative pressure in pleura, affecting the resting size of hemi thorax. e.g. In pneumothorax the negative pressure in pleura is lost and there is nothing to hold chest wall down. Hemi thorax on that side will assume TLC position. In patients with atelectasis the negative pressure in pleura increases and the size of hemi thorax will become smaller
Symmetry of Hemi thorax(Conti..)
It is best to assess symmetry of hemi thorax with patient laying flat in bed without pillows. Stand either at head or foot end and look tangentially at the thorax level to asses asymmetry.
Accessory Inspiratory Muscles
CHEST-PALPATION
Tactile Fremitus
CHEST—PERCUSSION
Percuss the lung fields, alternating, from top to bottom and comparing sides.
Percuss over the intercostal space and note the resonance and the feel of percussion.
Keep the middle finger firmly over the chest wall along intercostal space and tap chest over distal interphalangeal joint with middle finger of the opposite hand.
Percussion-Normal
The lung is filled with air (99% of lung is air). Hence, percussion of it gives a resonance. This step helps identify areas of lung devoid of air.
Appreciate the dullness of the left anterior chest due to heart and right lower chest due to liver.
Note the hyper-resonance of the left lower anterior chest due to air filled stomach.
Normally, the rest of the lung fields are resonant.
Normal diaphragmatic excursion is 5-6 cm.
Percussion- Abnormal
Dullness: (Mass, Atelectasis, Consolidation, Pleural effusion)
Hyper-resonance: (Emphysema, Asthma, Pneumothorax, Blebs)
Percussion- Abnormal A portion of the area of the heart thus mapped out is
uncovered by lung, and therefore gives a dull note on percussion.
The remainder being overlapped by lung gives a more or less resonant note.
The former is known as the area of superficial cardiac dullness, the latter as the area of deep cardiac dullness.
The area of superficial cardiac dullness is somewhat triangular; from the apex of the heart two lines are drawn to the midsternal line, one to the level of the fourth costal cartilage, the other to the junction between the body and xiphoid process; the portion of the midsternal line between these points is the base of the triangle.
CHEST-AUSCULTATION
Lungs-Auscultation-Order
Normal auscultatory sound
MAIN
Rt. Superior lobarSuperior lobar
Middle lobar
Inferior lobarInferior lobar
Secondary (lobar) bronchi
Tertiary bronchi—one for each BPS
Inhaled objects generally are found in right bronchus due to straighter pathway
Tracheal Breath Sounds: Loud, harsh, high pitched.
Bronchial Breath Sounds: Loud, high-pitched with air swishing past.
Bronchovesicular Sounds: Heard near branching of main bronchi, combination of bronchial and vesicular sounds.
Vesicular Sounds: Soft, low-pitched, airy, swishing, heard below the level of the bronchi
Auscultation of Lungs- Normal There are two normal breath sounds.
Bronchial and vesicular. Breath sounds heard over the tracheobronchial tree are called bronchial breathing and breath sounds heard over the lung tissue are called vesicular breathing. The only place where tracheobronchial trees are close to chest wall without surrounding lung tissue are trachea, right sternoclavicular joints and posterior right interscapular space. These are the sites where bronchial breathing can be normally heard. In all other places there is lung tissue and vesicular breathing is heard
Bronchial Breathing The bronchial breath sounds over the trachea has a higher pitch, louder, inspiration and expiration are equal and there is a pause between inspiration and expiration.
Vesicular Breathing The vesicular breathing is
heard over the thorax, lower pitched and softer than bronchial breathing. Expiration is shorter and there is no pause between inspiration and expiration. The intensity of breath sound is higher in bases in erect position and dependent lung in decubitus position
Vesicular Breathing(Conti..)
The breath sounds are symmetrical and louder in intensity in bases compared to apices in erect position. No adventitious sounds are heard.
Abnormal Finding
Intensity of breath sounds, in general, is a good index of ventilation of the underlying lung. If the intensity increases there is more ventilation and vice versa. Breath sounds are markedly decreased in emphysema
Bronchial breathing- anywhere other than over the trachea, right clavicle or right interscapular space is abnormal. Presence of bronchial breathing would suggest
Consolidation Cavitation Complete alveolar atelectasis with patent
airways Mass interposed between chest wall and
large airways Tension Pneumothorax Massive pleural effusion with complete
atelectasis of lung
Experienced physicians could discriminate between consolidation and cavitation by noting the quality of bronchial breathing. In consolidation, the bronchial breathing is low pitched and sticky and is termed tubular type of bronchial breathing. In cavitary disease, it is high pitched and hollow and is called cavernous breathing. You can simulate this sound by blowing over an empty coke bottle. In tension pneumothorax bronchial breath sounds has a metallic quality and is called amphoric breathing
PLEURAL FRICTION RUB: Grating sound heard during breathing that stops when the breath is held. Caused by friction of visceral and parietal pleura.
PULMONARY CONSOLIDATION: Occurs with late-stage lobar pneumonia.
BRONCHOPHONY: Increased transmission of sound to the lung periphery. Indicative of pulmonary consolidation
WHISPERED PECTORILOQUY: Words being understood better when whispered. Also indicative of pulmonary consolidation.
EGOPHONY: "E" to "A" sound-changes. Indicative of pulmonary consolidation or pleural effusion.
HAMMAN'S SIGN: Crunching, crackling sound over chest heard synchronous with the heart beat. Occurs with mediastinal emphysema -- air in the mediastinum.
CAUSES: Can follow thoracic surgery, trauma.
Boerhaave's Syndrome: Esophageal rupture causing air in mediastinum. Rare
Atelectasis: Bronchial plug ------> decreased lung volume ------> higher lung density ------> lung mass is pulled toward chest wall by negative pressure
Tracheal deviation toward affected side
no breath sounds
Bronchiectasis: Chronic bronchial dilation.
Caused by frequent pulmonary infections or pneumonia.
Large amounts of sputum will be expectorated when patient lies prone hanging toward floor.
Bronchitis: Acute (infectious) or chronic (smoker's)
Bronchiolitis: Common in infants and children
‘pink puffer’. Note the pursed-lip breathing
.
‘Blue bloater’ showing ascites from marked cor
pulmonale.
Conclusion Surface and regional anatomy are
important to a physician performing a physical exam, physicians must also understand the relationships of internal organs to interpret radiographs.
The position of the left nipple in males provides a guide for where to listen for various heart sounds.
Tracheal deviation could be either due to Lung, pleural, Mediastinal or Chest wall disease. The mediastinum can be either pulled or pushed away from the lesion.
Without proper knowledge of surface markings physicians may do harm to patients like-e.g.
A 52-year-old woman was admitted to the hospital with a diagnosis of right-sided pleurisy with pneumonia. It was decided to remove a sample of pleural fluid from her pleural cavity. The resident inserted the needle close to the lower border of the eighth rib in the anterior axillary line. The next morning he was surprised to hear that the patient had complained of altered skin sensation extending from the point where the needle was inserted downward and forward to the midline of the abdominal wall above the umbilicus.
The reason is needle was inserted too close to the lower border of the eighth rib and damaged the eighth intercostal nerve.
Anatomy of the Intercostal Space—VAN (Vein, Artery, and Nerve) Immediately below the rib above downwards.
Anatomy of the Intercostal Space
Vein
Artery
Nerve
Immediately below rib
BIBLIOGRAPHY
Anatomy of the Human Body, by Henry Gray.
Clinical Anatomy by Regions—by Richard S. Snell, 8th edition.
Human Anatomy, by B.D.Chaurasia, 4th edition.
www.gpnotebook.co.uk/simplepage.