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Elaine D.

Tan (Section D 2016)


Clinical Anatomy: Thoracic Wall
Identify the following first:

Sternoclavicular joint

Manubrium sterni

Costal margin

Costal arch

Midsternal line

Nipple at the 4th ICS

PLEURAL EFFUSION
Blunted costodiaphragmatic recess: effusion
CHEST EXAMINATION

Inspect

Palpate

Percussion

Auscultate

A. INSPECTION

Configuration of chest

Range of respiratory movements and any inequalities on the 2 sides

Type and rate of respiration are also noted

Asymmetrical Chest Exam

B. PALPATION

Note abnormal protuberances

C. PERCUSSION

Sharp tapping of chest wall with fingers

Vibration of air-containing organs:


o

Lungs resonant tone

Heart dull tone


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D. AUSCULTATION

Breath sounds

Diseased alveoli or bronchi lead to altered breath sounds

Too much air leads to hyperresonance


RIB AND COSTAL CARTILAGE IDENTIFICATION

The sternal angle is an important landmark.

Sternum and marrow biopsy:

Sternum retains hematopoietic properties throughout life

Wide-borne needle is inserted into its anterior surface

Sternum and heart surgery


o

Sternum is split at operation

Allows surgeon to gain easy access without having to enter pleural cavities

Two halves of sternum are sutured

Rib Excision
o

Gains entrance to thoracic cavity

Rib Fracture
o

Ribs 3 to 10 are the most commonly fractured

Inward displacement of fracture fragments may lacerate lining parenchyma or


intercostal vessels

Hemothorax vs. Pneumothorax

In pneumothorax, the lung is collapsed but the costodiaphragmatic


recess is sharp.

Flail Chest
o

When 2 or more contiguous ribs are broken in more than one place each

Cause paradoxical motion of chest wall

Breathing with resulting respiratory compromise

Intercostal Nerve Block


o

1st to 6th: Skin, Periosteum and Parietal Pleura


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7th to 11th: Skin and Parietal Pleura

Blocked before the lateral cutaneous branch arises at the midaxillary line

Internal Thoracic Artery in the Treatment of Coronary Artery Disease


o

Coronary artery disease is bypassed by inserting a graft:

Great Saphenous Vein

Internal Thoracic Artery

DEFORMITIES OF THE THORACIC WALL

Pectus Excavatum
o

Sternal depression

Funnel chest

Pectus Carinatum
o

Chicken-breast type

Kyphosis

Scoliosis

Lordosis



PLEURAL FLUID

Normal amount is 5 to 10 mL

In pleural effusion, becomes 300 mL


o

Leads to decreased lung expansion, decreased breath sounds and dullness


on percussion

PLEURAL EFFUSION

Hydrothorax

Hemothorax

Pyothorax or pleural empyema

Chylothorax


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