Inspection: Shape of Thorax E. 1. Stand in front of the patient. 2. Estimate visually and transverse diameter of the thorax. 3.

Move to either side of the patient. 4. Estimate visually the width of the anteroposterior (AP) diameter of the thorax. 5. Compare the estimates of these two visualizations. N. In the normal adult,, the ratio of the AP diameter to the transverse diameter is approximately 1:2 to 5:7. In other words, the normal adult is wider from side to side than from front to back.

The normal thorax is slightly elliptical in shape. A barrel chest is normal in infants and sometimes in the older adult.
A > In barrel chest, the ratio of the AP diameter to the transverse diameter is approximately 1:1. The patients chest is circular or barrel shaped in appearance. P > The patient with CPOD has a barrel chest due to air trapping and the alveoli and subsequent lung hyperinflation. A > Pectus carinatum, or pigeon chest, is a mark protrusion of the sternum. This increases the AP diameter of the thorax. P > Pectus carinatum can result from a congenital anomaly. A patient with severe pectus carinatum will exhibit respiratory difficulty.

P > Rickets results from a vitamin D deficiency. In this condition, the bones become demineralized and weak . The loss of bone strength allows the intercostal muscle to pull the ribs and the sternum forward, resulting in pectus carinatum.

A > Pectus excavatum, or funnel chest, is a depression in the body of the sternum. This identation can compress the heart and the cause myocarddial disturbances. The AP diameter of the chest decreases. P > Pectus excavatum results from a congenital anomaly. Respiratory insufficiency can ensue from the compression of the lungs in marked pectus excavatum. A > Kyphosis, or humpback, is an excessive convexity of the thoracic vertebrae. Gibbus kyphosis is an extreme diformity of the spine.

P > The majority of kyphosis cases are idiophatic. Respiratory compromise is manifested only on severe cases.
A > Scoliosis is a lateral curvature of the thorax or lumbar bertebrae. P > The majority of the cases o scoliosis are idiophatic, although iscoliosis can also result from neuromuscular diseases, connective tissue diseases and osteoporosis. Marked scoliosis can interfere with normal respiratory function. The total lung capacity and vital capacity decline in proportion to the severity of the scoliosis.

E. 1. Stand in the front of the patient. 2. Inspect the right and the left anterior thoraxes. 3. Note the shoulder height. Observe any differences between the two sides of the chest wall, such as the presence of masses. 4. Move behind the patient. 5. Inspect the right and the left posterior thoraxes, comparing right and left sides. 6. Note the position of the scapula. N > The shoulders should be at the same height. Likewise, the scapula should be the same height bilaterally. There should be no masses. A > Having one shoulder or scapula higher than the other is abnormal. P > The presence of scoliosis can lead to a shoulder or a scapula that higher than its corresponding part. Marked scoliosis impairs lung function. A > The presence of visible mass is banormal. P > A visible chest mass is always abnormal. Likely etiologies are mediastinal tumor or cyst. If large enough, they can compress lung tissue and impair normal lung function.

Presence of Superficial Veins E. 1. Stand in front of the patient. 2. Inspect the anterior thorax for the presence of dilated superficial veins. N. In the normal adult, dilated superficial veins are not seen. A. The presence of dilated superficial veins on the anterior chest wall is an abnormal finding. P. Dilated veins on the anterior thorax maybe indicative of superior vena cava obstruction. Due to the obstruction, the superficial veins and collateral vessels become engorged with blood and dilate. Venous return to the heart is diminished, compromising oxygenation. A patient may present with dyspnea.

Costal Angle E. Stand in front of the patient. 2. In a patient whose thoracic skeleton is easily viewed, locate the costal margins (medial borders created by the articulation of the false ribs. 3. Estimate the angle formed by the costal margins during exhalation and at rest. This is the costal angle. 4. In a heavy or obese patient, place your fingertips on the lower anterior borders of the thoracic skeleton. 5. Gently move your fingertips medially to the xiphoid process. 6. As your hands approach the midline, feel the ribs as they meet at the apex of the costal margins. Visualize the line that is created by your fingers as they move up the floating ribs toward the sternum.
1.

N > The costal angle is less than 90 during exhalation and at rest. The costal angle widens slightly during inhalation due to the expansion of the thorax. A > A costal angle greater than 90 is abnormal. P > Process where hyperinflation of the lungs (emphysema) or dilation of the bronchi (bronchiectasis) occurs also result in costal margin angle greater than 90. The diaphragm flattens out and the ribs are forced upward and outward, leading to change in the costal margin angle.

Angle of the Ribs E. 1. 2. 3. 4.

5.

Stand in front of the patient . In a patient whose thoracic skeleton is easily viewed, visually locate the midsternal area. Estimate the angle at which the ribs articulate with the sternum. In a heavy or obese patient, place your fingertips on the midsternal area. Move your fingertips along a rib laterally to the anterior axillary line. Visualize the line that is created by your hand as it traces the rib.

N > The ribs articulate at a 45 angle with the sternum. A > An angle greater than 45 is considered abnormal. Patients with particular respiratory pathology may have ribs that are nearly horizontal and perpendicular to the sternum.

P > Conditions characterized by an increased AP diameter, such as emphysema, bronchiectasis, and cystic fibrosis, result in an angle greater than 45 because the lungs are forced out due to hyperinflation or dilation of the bronchi.

Intercostal Spaces E. 1. Stand in front of the patient. 2. Inspect the ICS throughout the respiratory cycle. 3. Note any bulging of the ICS and any retractions. N. There should be an absence of refractions and of bulging of the CIS. A. The presence of refractions is abnormal. Refraction occurs