ASSESSMENT OF THE NORMAL THORAX AND LUNGS

Anatomy Overview
1. Thorax Anatomy:
o Boundaries: The thorax is bounded by the rib cage, sternum, thoracic vertebrae, and diaphragm.
o Components: It includes the thoracic cavity, which houses the lungs, heart, esophagus, and trachea.
2. Lung Anatomy:
o Lobes: The right lung has three lobes (upper, middle, lower), while the left lung has two lobes (upper,
lower).
o Pleura: Each lung is enveloped in a pleural membrane, with the visceral pleura covering the lungs and
the parietal pleura lining the thoracic cavity.
Physical Examination Steps
The assessment of the thorax and lungs involves four key steps: Inspection, Palpation, Percussion, and Auscultation.
1. Inspection
 Position and Preparation:
o Ensure good lighting.
o Position the patient sitting or in a semi-Fowler’s position.
o Expose the thorax while maintaining the patient's comfort and privacy.
 Observation Points:
o Thoracic Shape and Symmetry: Look for any deformities, asymmetry, or abnormal muscle retraction.
o Respiratory Rate and Rhythm: Count the respiratory rate (normal is 12-20 breaths per minute for
adults). Observe the rhythm (should be regular) and depth (normal, deep, or shallow).
o Effort of Breathing: Note if there is any use of accessory muscles or nasal flaring.
o Skin and Nails: Check for cyanosis, pallor, or clubbing of the fingers.
2. Palpation
 Technique:
o Use the pads of your fingers to palpate the thorax.
o Check for tenderness, masses, and crepitus (a crackling sensation under the skin).
 Chest Expansion:
o Place your hands on the lower back, thumbs together at the midline.
o Ask the patient to take a deep breath and observe the movement of your hands. Both sides should expand
equally.
 Tactile Fremitus:
o Have the patient say “ninety-nine” while you palpate with the ulnar side of your hand over different areas
of the chest.
o Normal fremitus is a faint vibration felt equally on both sides.
3. Percussion
 Technique:
o Perform percussion by tapping your fingers on the chest wall to produce sounds.
o Use the middle finger of one hand to strike the middle finger of the other hand placed on the chest.
 Normal Findings:
o Resonance: A hollow sound over the lung fields indicates normal air-filled lungs.
o Dullness: Over the heart, liver, or areas of lung consolidation.
o Hyperresonance: A booming sound may indicate emphysema or pneumothorax (though abnormal).
4. Auscultation
 Stethoscope Placement:
o Use the diaphragm of the stethoscope.
o Compare side to side, listening to one full breath at each site.
 Normal Breath Sounds:
o Vesicular: Soft, low-pitched sounds heard over most lung fields.
o Bronchial: Loud, high-pitched sounds heard over the trachea.
 o Bronchovesicular: Intermediate sounds heard over the major bronchi.
 Adventitious Sounds (though not normal, be aware of these for contrast):
o Crackles: Indicative of fluid in the alveoli.
o Wheezes: High-pitched sounds from narrowed airways.
o Rhonchi: Low-pitched sounds from secretions in large airways.
Conclusion
Assessing the thorax and lungs requires keen observation, methodical examination techniques, and an understanding of
normal versus abnormal findings. Regular practice and familiarity with normal variations are key to mastering this
essential skill. Always compare findings bilaterally and be mindful of patient comfort throughout the assessment.
Assessment of the Normal Abdomen
Anatomy Overview
1. Abdominal Regions:
o The abdomen is divided into four quadrants (right upper, left upper, right lower, left lower) or nine
regions (epigastric, umbilical, hypogastric/suprapubic, and the corresponding right and left
hypochondriac, lumbar, and iliac regions).
2. Internal Organs:
o RUQ: Liver, gallbladder, duodenum, head of the pancreas, right kidney and adrenal, hepatic flexure of
colon.
o LUQ: Stomach, spleen, left lobe of the liver, body of the pancreas, left kidney and adrenal, splenic
flexure of the colon, part of transverse and descending colon.
o RLQ: Cecum, appendix, right ovary and tube, right ureter, right spermatic cord.
o LLQ: Part of descending colon, sigmoid colon, left ovary and tube, left ureter, left spermatic cord.
Physical Examination Steps
The assessment of the abdomen involves four key steps: Inspection, Auscultation, Percussion, and Palpation. It’s crucial to
follow this order to avoid altering bowel sounds.
1. Inspection
 Position and Preparation:
o Ensure good lighting.
o Position the patient supine with a pillow under their head and knees slightly bent.
o Expose the abdomen while maintaining patient privacy.
 Observation Points:
o Contour: Observe the shape of the abdomen (flat, rounded, scaphoid, or protuberant).
o Symmetry: Check for any bulges, masses, or asymmetry.
o Skin: Look for scars, striae (stretch marks), veins, lesions, or rashes.
o Umbilicus: Note its position, shape, and any signs of inflammation or hernia.
o Movement: Observe for visible peristalsis or pulsations.
2. Auscultation
 Technique:
o Use the diaphragm of the stethoscope.
o Begin in the RLQ and proceed clockwise through the other quadrants.
 Normal Findings:
o Bowel Sounds: High-pitched, gurgling sounds occurring irregularly every 5-15 seconds.
o Vascular Sounds: Listen for bruits over the aorta, renal arteries, iliac arteries, and femoral arteries.
Normally, there should be no bruits.
3. Percussion
 Technique:
o Percuss lightly over all four quadrants.
 Normal Findings:
o Tympany: Predominant sound due to gas in the intestines.
o Dullness: Heard over solid organs like the liver and spleen, or when there is fluid or masses.
 Liver Span:
o Measure the liver span by percussing from the midclavicular line downwards from resonance to dullness
(upper border) and from tympany to dullness (lower border). Normal liver span is 6-12 cm.
 Splenic Percussion:
o Percuss the left lower anterior chest wall from the anterior axillary line to the midaxillary line. Dullness
may indicate splenomegaly.
4. Palpation
 Technique:
o Begin with light palpation to detect tenderness, muscular resistance, and superficial organs.
o Proceed to deep palpation to feel for masses and deeper organs.
  Normal Findings:
o Light Palpation: No tenderness or guarding.
o Deep Palpation: No masses; some structures may be palpable (e.g., liver edge in the RUQ in a thin
person).
 Specific Palpation:
o Liver: Palpate in the RUQ, under the costal margin. A normal liver edge is smooth, firm, and slightly
tender.
o Spleen: Normally not palpable. Palpate under the left costal margin.
o Kidneys: Usually not palpable. Palpate for enlargement or tenderness.
o Aorta: Palpate just left of the midline for pulsation. Normally, it should not be more than 3 cm wide.
Conclusion
Assessing the abdomen involves a systematic approach with inspection, auscultation, percussion, and palpation.
Understanding the normal findings helps in identifying abnormalities. Always ensure patient comfort and privacy during
the examination.