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@ Anterior chest – walk down

- Suprasternal notch, kanang buslot between clavicle

- 5cm down below this is sternal angle (Angle of Louis)
- 2nd rib is directly adjacent/kilid to angle of Louis
- 2nd ICS for needle insertion (tension pneumothorax)
- 4th ICS for chest tube insetion
- T4 for low margin ET tube on CXR
- Ribs 8, 9, 10 not attached to sternum; ga bitay kang 7th rib
- Ribs 11, 12 floating ribs
- 11th rib felt lateral
- 12th rib felt posterior
- Nerve and vascular vessels along inferior margin of every rib so mga needles and tubes placed or
penetrate along superior rib margin dapat

@ posterior chest – walk up

- Sugod kas 12th rib

- 7th rib covered by inferior angle of scapula/shoulder blade OR inferior angle lies on 7th ICS
- T7 to T8 ICS is landmark for thoracentesis with needle insertion (above 8th rib)
- C7 (spinous process of vertebrae) most prominent if neck is flexed forward (also T1)

Vertical lines imaginary sa thorax

- Midsternal, Midclavicular, anterior axillary line

- Midaxillary, anterior axillary, posterior axillary
- Vertebral line, scapular line

Lungs, fissures, lobes

- Apex of lung 2-4 cm above inner 3rd of clavicle

- Anteriorly, lower border of lung cross:
6th rib @ midclavicular line
8th rib @midaxillary line
- Posteriorly, lower border of lung:
T10 of spinous process
- Oblique/Major fissure: T3 spinous process to 6th rib midclavicular(both lungs)
- Horizontal fissure: 4th rib to oblique fissure midaxillary

Trachea and Bronchi

 - Bifurcation:
Sternal angle (anteriorly)
T4 spinous process (posterior)
- R main bronchi wider, shorter, more vertical = Aspiration Pneumonia prone = R middle and
lower lobe
- Main bronchi lobar bronchi segmental bronchi bronchioles alveoli

Pleura

- Visceral pleura = lacks sensory nerve

- Parietal pleura = rich in intercostal and phrenic nerves
- Transudate pleural effusions:
HF
Cirrhosis
Nephrotic syndrome
- Exudate pleural effusions:
Pneumonia
Malignancy
Pulmonary embolism
TB
Pancreatitis
- Parietal irritation produces= Pleuritic pain with deep inspiration

Breathing

- Automatic, brainstem is respi center

- Diaphragm = principal muscle of inspiration
- Inspiration = diaphragm contraction, descends, thoracic cavity expands
- Scalenes from cervical vertebraes to 1st two ribs
- Parasternal intercostal muscles/Parasternals from sternum to ribs
- Decrease intrathoracic pressure = musulod ang hangin
- Expiration = chest wall + lung recoil, diaphragm relaxes and rises passively
- Abdominal muscles assist in expiration

History

Common concerning sx:

1. Chest pain
2. SOB/Dyspnea
3. Wheezing
 4. Cough
5. Hemoptysis
6. Sleepiness/Sleeping dso or snoring

Chest pain

- Sources:
GI
Cardiovascular
Chest wall
Pulmonary
- Angina Pectoris = clenched fist over sternum
- Musculoskeletal pain = finger point to a tender spot on chest wall
- Heartburn = from neck to epistrium
- Lung tissue no pain fibers, dapat inflammation pa sa adjacent parietal pleura or prolonged
cough
- Pericardium few pain fibers, dapat inflammation pud sa adjacent parietal pleura

Dyspnea

- Degree of SOB + spirometry = COPD key component

- With anxiety:
Episodic with rest and exercise
Hyperventilation (rapid shallow breathing)
- Paresthesis = tingling sensation or “pins and needles” around lips or in the extremities

Coughing

- Can signal L HF
- Acute = < 3 weeks:
 Viral (most common)
 Acute bronchitis
 Pneumonia
 L HF
 Asthma
 Foreign body
 Smoking
 Ace inhibitor drugs
- Subacute = 3 to 8 weeks
 Postinfections
 Pertussis
 Acid reflux
  Bacterial sinusitis
 Asthma
- Chronic = > 8 weeks
 Postnasal drip
 Asthma
 GERD
 Chronic bronchitis
 Bronchiectasis
- Mucoid sputum = translucent, white, gray (viral and cystic fibrosis)
- Purulent sputum = yellow, green (bacterial pneumonia)
o Large vol = bronchiectasis and lung abscess
- Foul smell sputum = anaerobic lung abscess
- Thich tenacious sputum = cystic fibrosis
- Fever and productie cough = Pneumonia
- Wheezing = asthma
- Chest pain, dyspnea and orthopnea = ACS

Hemoptysis

- From lower respiratory tract

- Massive hemoptysis, life threatening:
Goodpasture syndrome
Wegener granulomatosis

Daytime sleepiness/ Snoring and Sleep dso

- Apneas = > 10 seconds

- Awakening with choking sensation
- Morning headache
- Obstructive sleep apnea hallmarks:
Daytime sleepiness + snoring
With obesity
Retrognathia = maloclussion of the jaw
Resistant hpn
HF
Atrial fibrillation
Stroke
DM 2
- Genioglossus malfunction = disordered contraction of upper airway muscles