Thorax, Lungs & Breast Assessment – Lecture Review

Thorax & Lung Assessment

Key Take-Home Mantras

• “Pads not tips” – use the pulp of fingers for palpation; many more nerve endings than on the fingertips.
• Read/listen in a ladder pattern – ALWAYS compare Right → Left at each interspace.
• Stethoscope on SKIN, diaphragm side, never through clothes.
• Full respiration at every spot; tell patient: “Each time you feel the scope, take a deep breath through your mouth.”
• AP : Transverse ratio in healthy adult = 1:2 ; COPD/barrel chest → 1:1.

Anterior Bony Landmarks

• Suprasternal (jugular) notch – U-shaped dip above manubrium; always locate first.
• Sternum parts – Manubrium, Body, Xiphoid process.
• Sternal Angle (Angle of Louis) – junction of manubrium & body; level of 2nd rib & 2nd ICS; tracheal bifurcation & upper atria lie here.
• Costal Angle – where R/L costal margins meet xiphoid; normal \le 90^{\circ} (wider in chronic hyper-inflation/COPD).

Posterior Landmarks

• C7 – most prominent spinous process when head flexed; marks lung apex.
• Spinous processes T1–T12 – count downward; vertebral line is mid-back reference.
• Inferior scapular angle ≈ 7th–8th rib.
• 12th rib – free tip palpable between spine & mid-axillary line.

Reference Lines (memorise for lung & cardiac exams)

• Mid-sternal line
• Mid-clavicular line (MCL)
• Anterior / Mid / Posterior Axillary lines
• Vertebral (spinal) line
• Scapular line (through inferior angle)

Lung Borders & Lobes

• Apex = top; Base = bottom (flat).
• Anterior: Apex 3–4 cm above inner third of clavicles; Base ~6th rib MCL.
• Posterior: Apex = C7; Base = T10 (may descend to T12 on deep inspiration).
• Right lung – 3 lobes (upper, middle, lower); shorter (liver pushes up).
• Left lung – 2 lobes; narrower (heart indents – cardiac notch).

Pleura & Pleural Space

• Double, slippery membrane → friction-free lung movement.
• Inflammation = pleurisy; produces sharp pain & possible pleural friction rub.

Respiratory Physiology (4 main functions)

1. O₂ supply.

2. CO₂ removal.

3. Acid–base balance.

4. Heat exchange (mainly infants).

• Breathing is involuntary, brain-stem–controlled.
• Primary drive = ↑CO₂ (hypercapnia). ↓O₂ (hypoxemia) is secondary.
• Inspiration: diaphragm ↓, ribs ↑ & out.
• Forced inspiration uses sternocleidomastoids, scalenes, pectoralis.
• Forced expiration uses abdominals & internal intercostals.

Subjective Assessment Cues

Ask about:
• Cough (acute \le 3 wk / chronic >8 wk); timing, triggers, sputum colour.
• SOB (onset, exertional vs rest, orthopnea).
• Chest pain with breathing.
• Past respiratory illnesses (TB, asthma, pneumonia, bronchitis).
• Smoking/vaping (packs-year, cartridges-day).
• Occupational/environmental exposures (miners, farmers, factory, chemical disinfectants, radiation badges).
• Self-care: vaccines, masks, pillows for reflux, etc.

Ageing Lung Changes

• ↓ respiratory muscle strength → ↑ residual volume.
• ↓ chest wall compliance (stiff ribs, kyphosis).
• ↓ cilia number, ↓ alveolar surface area, ↓ elastic recoil.
• Weaker cough → retained secretions, ↑ risk atelectasis & infection.

Examination Sequence

1. Inspect (always first)

2. Palpate (unless abdomen → auscultate before palpation)

3. Percuss

4. Auscultate

1 Inspection

• Shape: symmetry, deformities, AP:T ratio 1:2.
• Skin: colour (pink for ethnicity), lesions, scars, turgor (pinch below clavicle – should snap back; tenting = dehydration).
• Respiratory pattern: effortless, regular, silent.
• Consciousness & facial expression (restless, anxious = hypoxia/PE).
• Posture: COPD pts often tripod with pursed-lip breathing.

2 Palpation

• Posterior chest expansion – thumbs at T9–T10, pinch skin fold, deep breath → thumbs move symmetrically.
• Tactile fremitus – palmar/ulnar surface; “99” at each ladder point. ↓ fremitus (pleural effusion, pneumothorax, COPD). ↑ fremitus (pneumonia).
• Entire surface for tenderness, masses, temperature (dorsal hand), crepitus (sub-Q emphysema feels like Rice Krispies).

3 Percussion (rare clinically today)

• Compare side-to-side every ~5 cm, avoid scapula/ribs.
• Normal = resonance (low-pitched, hollow). Dull over muscle, liver, tumour; hyper-resonant in emphysema, pneumothorax.

4 Auscultation

• Patient sitting, leaning slightly forward, arms across lap to move scapulae laterally.
• Ladder pattern: start above clavicles, 8–9 points posterior; 6–8 anterior; include RML (right mid-axillary 4th–5th ICS).
• Listen for one full inspiration & expiration each spot.
• Normal sounds (p.425):
– Bronchial (tracheal): high, loud, hollow, heard over trachea.
– Broncho-vesicular: moderate pitch, over main bronchi (1st–2nd ICS & between scapulae).
– Vesicular: low, soft, rustling over peripheral lung fields.

Voice Tests

• Bronchophony – “99” → should be muffled. Clear = consolidation.
• Egophony – “eee” → heard as “aaa” over consolidation.
• Whispered pectoriloquy – whisper phrase → faint/muffled is normal; loud = pathology.

Adventitious Sounds & Pathologies

• Fine crackles – popping; CHF, pneumonia, fibrosis.
• Coarse crackles – bubbling; pulmonary edema, terminally ill airway occlusion.
• Pleural friction rub – grating leather; pleurisy.
• Wheeze (sibilant) – musical; asthma, COPD.
• Wheeze (sonorous/rhonchi) – low snore; bronchitis.
• Stridor – high crowing, upper airway obstruction (emergency).

Common conditions & key signs:
• Atelectasis – collapsed alveoli, ↓ expansion, ↓ breath sounds.
• Pneumonia – ↑ fremitus, crackles, bronchophony, dull percussion.
• Pleural effusion – ↓ fremitus, dull, absent sounds.
• Pneumothorax – unequal expansion, hyper-resonance, ↓ fremitus.
• COPD/Emphysema – barrel chest, tripod, pursed lips, hyper-resonance, decreased sounds.
• Acute bronchitis – <3 wk, productive cough, no crackles/wheezes. • Lung cancer – weight loss, non-specific pain, hemoptysis, clubbing (>180^{\circ} nail angle).

Breast & Axilla Assessment

Quadrants & Tail of Spence

• Divide each breast into 4 quadrants with imaginary cross through nipple.
• Upper Outer Quadrant extends into axilla → Tail of Spence = most common cancer site.

Inspection (sitting or standing)

Look for symmetry, contour, skin, venous pattern, lesions, dimpling/puckering, nipple position & discharge.
Positions to uncover subtle retraction:

1. Arms at sides → baseline.

2. Arms over head.

3. Hands on hips & press (contracts pectoralis).

4. Lean forward (pendulous breasts swing freely).

Palpation Technique (lying supine, arm raised)

• Use pads of 3 fingers, small circular motion, light → medium → deep pressure.
• Vertical strip pattern (recommended): start at sternum, move up & down across breast to mid-axillary line incl. Tail of Spence; then nipple, compress for discharge.
• Note lump characteristics:
– Location (clock + cm from nipple)
– Size (L × W × D)
– Shape (oval, round, irregular)
– Consistency (soft, firm, hard)
– Mobility (mobile vs fixed)
– Delimitation (well-circumscribed vs matted)
– Tenderness
– Overlying skin changes
• Axilla – palpate central, anterior, posterior, lateral nodes.

Normal / Age-Related Findings

• Adolescent “breast bud” (Tanner staging).
• Pregnancy – vascular pattern, nodularity, colostrum.
• Older woman – estrogen ↓ → atrophy, pendulous, granular feel.

Breast Self-Exam (BSE) Teaching Points

1. Best time: 4–7 days after menses; for post-menopausal pick same day monthly.

2. Mirror inspect; raise arms; look for changes.

3. In shower or supine, use vertical strip pattern.

4. Report any new lump, dimpling, nipple change, discharge.

Male Breast / Gynecomastia

• Benign estrogen > testosterone ratio; seen in puberty, aging, Cushing, liver cirrhosis, hyperthyroid, certain drugs.
• Males can develop carcinoma – assess any unilateral, hard, fixed mass, nipple retraction.

Quick Tables / Numbers to Memorise

• Costal angle normal \le 90^{\circ}.
• Lung apex above clavicle 3–4 cm.
• Base: T10 (rest) to T12 (deep insp.).
• AP:T chest ratio normal 1:2; barrel 1:1.
• Acute cough \le 3 wk; Chronic >8 wk.
• Normal RR adult 10–20\,\text{breaths/min}.
• Clubbing = nail angle >180^{\circ}.