PRE-CLINICAL CLERKSHIP, YEAR 1, 2005/2006`

Physical Examination, Session Three: Lung Sounds
Cheryl A. Walters, M.D.

Visible Human Images
Lawrence J. Rizzolo, Ph.D.

1. Learning Objectives

• To outline on the chest, the lobes of the lung.
• To outline on the chest, maps for auscultation and percussion.
• To practice the techniques of auscultation and percussion.
• To describe and appreciate the defining features of vesicular, bronchovesicular, and bronchial breath sounds.
• To develop a flow for the head to toe exam.

2. Student Prep

• Read pp. 315-320, 327-338, Chapter 12 The Chest
• View the companion portion of the CD
• View VH Dissector Pro exercise

Practice Exercises:  Identify on the anterior chest of yourself or partner, the sternal angle or angle of Louis (the level of the carina), midclavicular line (MCL), anterior axillary line (AAL), and 4-6th right intercostal spaces (the 4th ICS is at the level of the nipple).

The VH Pro image shows the clavicle and 1st rib (to infer the sternal notch), 2nd rib (to infer the angle of Louis) and the 4th and 6th ribs.  The sternum heart and great vessels are omitted.

Use the sliders to add or remove skin, change the angle of rotation, or resize the image. Click <alt-p> on the image to change the cross-section.

On the posterior chest, begin by bending the neck forward to find C7 (vertebra prominens). Outline the upper lobes from T1-T4, and the lower lobes from T4-T10. (To appreciated this point you must rotate the image to distinguish the posterior surfaces of the lung from the rest.)

On the right lateral chest, outline the right middle lobe (RML) between the right 4-6th intercostal spaces.

Listen to the recording of lung sounds on the CD (see your syllabus for details). 

3. Clinical Anatomical Landmarks

• Bony chest -- sternum, 12 ribs, 12 thoracic vertebrae
• Anterior chest: (Use ctrl-P (or command-p on a mac) to be sure the plane of section is turned on)

  Suprasternal notch
  Sternal angle (angle of Louis)—level of the carina and second rib; 2nd intercostal space is below it
  Mid Clavicular Line (MCL)
  Right 4th rib (level of nipple and horizontal fissure separating RUL and RML -- rotate image to appreciate this)
  Left 6th rib (level of oblique fissure separating LUL and LLL -- rotate image to appreciate this) - look on the axial section to see the inferior-most reach of the upper lobe
  Anterior maps for auscultation and percussion
  Xiphoid process

• Posterior chest:

  C7 vertebra prominens, and T1
  T4 (level of oblique fissure separating UL's and LL's)
  
  Rotate image to appreciate this The axial view shows a hint of the lower lobes posteriorly. Therefore in this patient, the fissure projects a little higher at T3
  .............This is just an example of normal anatomical variation

  Posterior maps for auscultation and percussion

• Lateral chest:

  Anterior Axillary Line (AAL)
  Mid Axillary Line (MAL)
  4th rib (level of nipple and horizontal fissure separating RUL and RML)
  6th rib (level of oblique fissure separating RML and RLL)
  Lateral maps for auscultation and percussion

Posteriorly 12 thoracic vertebrae; areas accessible for evaluations of lung sounds – maps for auscultation and percussion -- will be in the areas between the T-spine and scapulae and below the scapulae

To eyeball where T1 is, have your partner flex his neck and the most prominent vertebral body is C7; T1 is just below it.

For the following discussion, rotate the following images: Upper lobe only, lower lobe only, all lobes

• Posterior approach to lobes-the UL's and LL's are separated by the oblique fissures at T4. The posterior approach captures the UL's from T1 to T4 and the LL's from T4 to T10 (T12 on deep inspiration).
• Anterior approach to lobes—the LUL apex extends above clavicle and lobe is separated from the LLL by the oblique fissure at the level of the sixth rib.
• RUL apex extends above clavicle and is separated from the RML by the horizontal fissure at the 4th rib (nipple). A reasonable approach is to listen and percuss the UL's in the MCL and to the level of nipples in male patients and just above the breasts in female patients.
• RML—separated from the RUL by the horizontal fissure at the 4th rib (level of nipple), and RML is separated from the RLL by the oblique at the 6th rib. Listening and percussing are best between the 4th and 6th ribs between the anterior and mid axillary lines.

4. List of Maneuvers to be Demo/Practiced  See syllabus for details
5. Procedural Tips See syllabus for details
6. Perceptual Tips See syllabus for details
7. Description of Key Features See syllabus for details

©2007 Cheryl Walters, Lawrence Rizzolo, Yale School of Medicine