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416 PHYSICAL EXAMINATION
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HEALTH HISTORY
UNIT 2
STRESS Bills and home mortgage concerns; has a very stressful job
EDUCATION High school graduate, TAFE diploma (Business studies)
ECONOMIC STATUS Middle socioeconomic status
RELIGION Roman Catholic
CULTURAL
BACKGROUND
ROLES AND
RELATIONSHIPS
CHARACTERISTIC
PATTERNS OF
DAILY LIVING
HEALTH MAINTENANCE
ACTIVITIES
SLEEP 7 hours/night. Some nights not sleeping well due to worry about work
DIET States she tries to eat a well-balanced diet, does have take-away fast-food on a regular
EXERCISE Tries to get to the gym twice a week, occasional walk after dinner for 20 minutes
STRESS MANAGEMENT Prayer, walking, talking to mother/friend. States that she does have a lot of stress
USE OF SAFETY DEVICES Wears seat belts, smoke detector in home
HEALTH CHECK-UPS Last gynae exam and clinical breast exam 8 months ago, regularly is breast aware
PHYSICAL EXAMINATION
Anglo-Saxon (Born in London, UK)
Friend, employee; she is close to her family and sisters
Wakes at 7 a.m. (twice a week gets up at 6 a.m. to go to the gym), breakfast usually
cereal and coffee, at work by 8 a.m.; usually has two more coffees before midday,
eats lunch – a salad or sandwich and coffee – works until 4:30 p.m., arrives home
by 6 p.m., eats dinner – meat and vegetables – occasionally walks after dinner,
watches TV with cup of coffee, in bed by 11 p.m.
basis (high-fat/high-salt diet). She is aware that she should cut back on amount of
coffee she has a day. Also enjoys chocolate regularly, stating she is a ‘chocoholic’
with her job
for changes
INSPECTION COLOUR Breast and axilla are esh coloured with the areolar area and nipples darker
pigmentation, no naevi
VASCULARITY No enhanced vascular pattern
THICKENING OR
OEDEMA
SIZE AND SYMMETRY Large, pendulous breasts, appear symmetrical, no nipple inversion or distortion
CONTOUR Convex in shape
LESIONS OR MASSES Nil noted
DISCHARGE Nil discharge
PALPATION SUPRACLAVICULAR
AND INFRACLAVICULAR
LYMPH NODES
BREASTS: CONSUMER
IN SITTING POSITION
AXILLARY LYMPH
NODE REGION
BREASTS: CONSUMER
IN SUPINE POSITION
There is no appearance of thickening or oedema at present
of nipples
Nonpalpable
A single rm well-dened and mobile palpable round mass approx. 2cm in size is
felt in the upper outer quadrant of the right breast; consumer states it is tender
A palpable lymph node of <1cm noted
A single rm well-dened and mobile palpable round mass approx. 2 cm in size is felt in the
upper outer quadrant of the right breast; consumer states it is tender, no nipple discharge
>>
BREASTS AND REGIONAL NODES 417
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DIAGNOSTIC DATA
MAMMOGRAPHY No abnormalities detected
STEREOTACTIC BIOPSY No uid is apparent on aspiration biopsy of the lesion
EXCISIONAL BIOPSY Has now been taken, pathology report not received as yet
EVALUATION AND CLINICAL
REASONING FOR CASE STUDY
The assessment and clinical decisions you make should reect
your scope of practice. For example, advanced practice health
professionals, such as nurse practitioners and remote area nurses
with endorsement, may be able to make diagnostic decisions and
prescribe medications without referring to a medical ofcer.
Fundamentally, all health professionals collect, evaluate and
act on consumer-focused health information, which will at times
include referral to, or collaboration with, other healthcare team
members. Nurses assess consumer responses to
and determine when to escalate key changes in a consumer’s
condition. The clinical reasoning cycle provides health
professionals with a framework to consider all this information
in a meaningful way for planning consumer care. These phases
are stepped out below, and draw on information presented and
collected during the health history and physical examination.
Wethen work through the cycle components that are relevant to
this case study (cycle components are bolded).
For Holly Hastings, the signicant data that needs to be
considered includes the following.
Collecting cues/information
Recall and Review: In the rst instance you will need to reect
on what you know about breast lumps and more specically
brocystic breast changes. These benign changes to breasts
are very common in women 30–50 years of age, rare in
postmenopausal women. It is not a disease as such, as it relates
to uctuations in hormones. Women who suffer from premenstrual
abnormalities, are nulliparous, have never taken the contraceptive
pill and had early menarche are more susceptible to this disorder.
The symptoms include swelling, pain, tenderness, lumpiness and
nipple discharge (which may or may not be present) and these
increase just before menstruation. On examination: one or more
palpable lumps that are round, soft to rm, well dened and freely
movable can be felt. Some will be cysts full of uid, while others
can be brous with no uid. It should be noted that brocystic
changes do not increase the chances of breast cancer in the
majority; however, women with this disorder should have frequent
clinical check-ups with the GP.
Medical management following a complete health history,
examination with imaging studies, if not conclusive, a biopsy for
denitive diagnosis, is usually based on palliating the symptoms.
These include medication such as analgesics, diuretics, hormone
therapy and antioestrogen therapy. Danazol, a synthetic androgen,
can be prescribed for consumers with severe pain. Many other
interventions
interventions can also be suggested to alleviate the disorder,
such as diet (low salt, restrict methylxanthines found in chocolate
and coffee), reduction of stress (a common contributing factor
for breast disorders), stopping smoking (women who stop have
reported a reduction in the lumpiness of their breasts), vitamin E
therapy and/or local heat and cold therapy may assist in reducing
swelling and pain. These interventions remain experimental as
there has been no research as to their effectiveness; hence it is
trial and error for each individual woman.
Taking all this into consideration when you are processing
Holly Hastings’ information will allow you to undertake the clinical
reasoning cycle appropriately.
Chief complaint and history of present illness
> Consumer states she is worried she has breast cancer.
> She has discovered a lump in the upper outer quadrant of her
right breast.
> She complains of frequent breast tenderness, lumpiness
andswelling.
> History of brocystic disorder.
Processing information
Interpret: These symptoms and details of history outline the scope
of the issue for this consumer and how it is affecting her wellbeing
and ability to self-manage this deviation from normal health.
Medication
> Taking a multivitamin.
Relate and Discriminate: At present she appears to be treating
her stress by commencing a multivitamin. It would be important to
nd out if she has in the past taken any analgesia for the breast
tenderness and if so what type and how effective it was.
Taking Levlen (contraceptive pill).
Relate and Discriminate: Holly has reported having severe
dysmenorrhea, and has recently commenced taking Levlen to
assist with this.
Social history
> Not in a relationship at present and is nulliparous.
> Has a very stressful job.
Discriminate: Need to consider these things as it has been
identied that women who are nulliparous and suffer from stress
are more susceptible to this disorder.
Health maintenance activities
> Drinks a considerable amount of coffee.
> States she is a ‘chocoholic’.
CHAPTER 12
418 PHYSICAL EXAMINATION
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Interpret and Relate: Coffee and chocolate contain methylxanthines
and it is believed that this contributes to brocystic changes, so it is
signicant information relating to her present health alteration.
UNIT 2
Physical examination/diagnostic data
> A single rm, well-dened and mobile palpable round mass
approx. 2cm in size is felt in the upper outer quadrant of the
right breast; consumer states it is tender.
> Nil abnormalities detected on mammography.
> Stereotactic biopsy, nil uid aspirated.
> Excisional biopsy – has now been taken, awaiting results.
Infer and Predict: These ndings give an indication that the lump
is probably brocystic; however, the excisional biopsy will give a
denitive diagnosis. This is signicant as the consumer has not
received the results yet, so she will still be quite anxious re the
possibility she has breast cancer.
Putting it all together – synthesise information
The role of the nurse in this case is primarily emotional support
and teaching. As Holly Hastings will be discharged before she
receives the results of her test, relieving her anxieties will be
paramount. Also, providing further information about contributing
factors to her health alteration, so that she can self-care and use
comfort measures, will aid her in managing this disorder.
Actions based on assessment ndings
The nurse should provide additional information/education for
interventions that do not require a doctor’s order. These would include:
1 Encourage her to express any fears and anxieties that she may
have in relation to her possible diagnosis of breast cancer and
answer her questions honestly.
2 Give Ms Hastings further information about brocystic
disorders – that it is a common disorder in premenopausal
women, and is also more prevalent in women who suffer from
premenstrual conditions (such as severe dysmenorrhea).
3 Explain that the majority of breast lumps, approx. 80%, are
benign, and that brocystic changes do not increase the risk
ofbreast cancer.
4 Educate her re the use of analgesia to assist her to cope
with the tenderness and discomfort of her breasts pre
menses, specically with NSAIDs (commence taking as
soon as breasts feel tender to maximise effect, correct
dose250–500mg tds).
5 Encourage Holly to wear a well-tted and supporting bra,
asthis will reduce feeling of weight and thus pain.
6 Discuss/encourage her to decrease/eliminate caffeine and
chocolate from her diet, especially close to her menses.
7 Taking a vitamin E supplement may relieve swelling and
tenderness, especially right before her menstrual period.
8 Hot or cold packs can also relieve pain and swelling.
9 As stress has been linked to breast discomforts – discuss ways
to manage/decrease stress (exercise, balanced diet, work–life
balance, adequate sleep etc.).
10 Encourage her to continue to be breast aware, as well as visit
her GP for clinical examinations as they suggest. (Possible
mammogram regularly.)
The nal step in the process is accurate documentation. The
nurse must document ndings, referrals, interventions, and advice
and education given. The consumer would be advised to make an
appointment to see her surgeon as requested to discuss results
and further management of her breast disorder.
CHAPTER RESOURCES
REVIEW QUESTIONS
For answers to these questions, see Answer section at the end
ofthe book.
1. Abby, a 12-year-old female, is having a physical examination.
She tells you that she began her menses at age 10 and she
is 160cm tall. On examination you see that her nipple is ush
with the breast. The areola and breast are larger than a
smallmound. What is Abby’s sexual maturity rating stage for
breast development?
a. 1
b. 2
c. 3
d. 4
2. Which breast structure is a sebaceous gland that lubricates
the nipple and helps to keep it supple during lactation?
a. Montgomery’s tubercles
b. Ectodermal galactic band
c. Cooper’s ligaments
d. Tail of Spence
3. A 16-year-old female presents to clinic with complaints of
‘multiple moles’ on her breast. Upon inspection, the Women’s
Health nurse observes an ectodermal galactic band extending
from the axilla to the groin. The nurse explains to the consumer
that they are not moles, but they are which of the following?
a. Montgomery tubercles
b. Lymph nodes
c. Supernumerary nipples
d. Areola
BREASTS AND REGIONAL NODES 419
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4. Which of the following conditions is found most commonly in
postmenopausal women?
a. Mastitis
b. Paget’s disease
c. Fibroadenoma
d. Cystic hyperplasia
5. A consumer visits the health clinic because she has been
experiencing nipple discharge for a few weeks. You review
her health history. Which of the following medications may
have a link to breast discharge?
a. Theophylline
b. Chemotherapy
c. Hormone replacement
d. Chlorpromazine
6. Which of the following recommendations by BreastScreen
Australia and the New Zealand Breast Cancer Foundation is
true for breast health checks in a 35-year-old woman?
a. Breast self-awareness
b. Clinical breast examination
c. Annual mammogram
d. Baseline breast MRI
7. Which of the following are nonmodiable risk factors for
developing breast cancer? Select all that apply.
a. Age greater than 50
b. Family history with breast cancer
c. Male sex
d. Personal history of breast cancer
e. Obesity
f. Postmenopausal hormone therapy
8. Which type of breast cancer starts in the lobules and milk
ducts and has invaded outlying tissue?
a. Ductal carcinoma in situ
b. Invasive ductal carcinoma
c. Inltrating lobular carcinoma
d. Paget’s disease
9. Which of the following would identify that a woman is at high
risk of developing breast cancer?
a. Multiple (blood) family members with a diagnosis of
breast cancer
b. Previous history of breast cancer
c. Family (blood) member with hereditary mutation
(e.g.BRCA1/BRCA2)
d. All of the above
10. Carolyn, a 26 -year-old nonlactating female, presents with a
complaint of a single, nontender breast mass she found during
a self-breast examination. The consumer describes the mass
as rm, well dened and mobile. The nurse suspects which of
the following?
a. Cyst
b. Fibroadenoma
c. Mastitis
d. Carcinoma
CLINICAL SKILLS
The following Clinical Skill is relevant to this chapter and can
be found in Tollefson & Hillman, Clinical Psychomotor Skills,
8thedition:
> 27 Healthcare teaching.
CHAPTER 12
FURTHER RESOURCES
> Australian Breast Cancer Research: https://www.abcr.com.au/
> Australian Government Department of Health – Breast
Screen Australia Program: http://www.health.gov.au/internet/
screening/publishing.nsf/Content/breast-screening-1
> Australian National Breast Cancer Foundation: https://nbcf.org.au/
> Breast Cancer Cure – New Zealand Breast Cancer Research
Trust: https://www.breastcancercure.org.nz/
> Breast Cancer Network Australia: http://www.bcna.org.au
> Breast Cancer Trials: http://www.bcia.org.au
> Cancer Australia, Australian Government – Breast Cancer:
https://breast-cancer.canceraustralia.gov.au/
REFERENCES
Australian Institute of Health and Welfare (AIHW). (2021). Cancer in Australia
2021. Cancer series no. 133. Cat. no. CAN 144. Retrieved 12 December 2022
from https://www.aihw.gov.au/reports/cancer/cancer-data-in-australia/
Breast Cancer Foundation New Zealand. (2022). Retrieved 12 December
2022 from https://www.breastcancerfoundation.org.nz/breastawareness/breast-cancer-facts/breast-cancer-in-nz
> Inammatory Breast Cancer Research Foundation:
http://www.ibcresearch.org
> Ministry of Health, New Zealand: http://www.health.govt.nz/
> National Breast Cancer Foundation: https://nbcf.org.au/about-
national-breast-cancer-foundation/about-us/
> National Screening Unit – Breastscreen Aotearoa: http://
www.nsu.govt.nz/current-nsu-programmes/breastscreenaotearoa.aspx
> New Zealand Breast Cancer Foundation: http://www.nzbcf.
org.nz/
Breast Cancer Network Australia. (2022). Risk factors. Retrieved
12 December 2022 from https://www.bcna.org.au/breast-healthawareness/risk-factors
Breast Cancer Trials. (2022). Breast cancer statistics. Retrieved
12 December 2022 from https://www.breastcancertrials.org.au/
breast-cancer-resources/breast-cancer-statistics/
420 PHYSICAL EXAMINATION
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
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BreastScreen Australia. (2022). Department of Health Australian
Government. Retrieved 7 May 2022 from http://cancerscreening.gov.au/
internet/screening/publishing.nsf/Content/breast-screening-1
Cancer Australia. (2022). Breast cancer. Retrieved 12 December 2022
UNIT 2
from https://www.canceraustralia.gov.au/cancer-types/breastcancer/statistics
National Breast Cancer Foundation. (2022). Breast cancer and Aboriginal
and Torres Strait Islander peoples. Retrieved 12 December 2022 from
https://nbcf.org.au/about-breast-cancer/further-information-on-breastcancer/breast-cancer-in-aboriginal-and-torres-strait-islander-peoples
NZ National Screening Unit. (2022). Breast screening. Retrieved 6 May 2022
from https://www.timetoscreen.nz/breast-screening/
Tin Tin, S., Elwood, M., Brown, C., Sarfati D., Campbell I., Scott, N., …
Lawrenson R. (2018). Ethnic disparities in breast cancer survival in
New Zealand: Which factors contribute? BMC Cancer, 18 (1), 58,
doi 10.1186/s12885-017-3797-0
CHAPTER
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13
RESPIRATORY
LEARNING OUTCOMES
By the end of this chapter you should be able to:
1 identify the anatomic landmarks of the thorax and the lungs
2 describe the characteristics of the most common respiratory complaints
3 obtain a health history from a consumer with a respiratory problem
4 demonstrate inspection, palpation, percussion and auscultation on a healthy adult and on a consumer
with a respiratory problem
5 discuss the clinical reasoning in evaluating outcomes of health assessment and physical examination,
including documentation, health education provision and relevant health.
421
BACKGROUND
Respiratory health problems affect a person’s airways and produce symptoms
such as shortness of breath, chest tightness, cough and wheezing. In the 2020−21
reference period, 1 in 3 Australians (ABS, 2022) and 1 in 7 New Zealanders (Asthma
and Respiratory Foundation NZ, 2022a) reported having chronic respiratory
conditions. These include asthma, chronic obstructive pulmonary disease (COPD)
(encompassing emphysema and chronic bronchitis), allergic rhinitis or ‘hay fever’,
chronic sinusitis, bronchiectasis, cystic brosis, occupational lung diseases and sleep
apnoea (AIHW, 2022a). The Severe Acute Respiratory Syndrome Coronavirus (SARSCoV-2) that causes coronavirus disease (COVID-19) and the subsequent worldwide
pandemic has created signicant challenges and changes to the respiratory health of
many people. To date, Australia has experienced over 11 million cumulative cases of
COVID-19 (COVID Live, 2023), and New Zealand has experienced almost
2.5 million cumulative cases of COVID-19 (Ministry of Health, 2023).
Between 2017 and 2021 the most common cause of respiratory-related deaths
in Australia, and the fth most common overall, was chronic lower respiratory
disease (ABS, 2022); in New Zealand asthma and respiratory disease was the third
leading cause of death (Asthma and Respiratory Foundation NZ, 2022a). In 2021
in Australia, the mortality rate from respiratory diseases was very low, at a rate of
39.1 per 100000 people (ABS, 2022), with cancer of the lung, trachea and bronchus
accounting for 8674 deaths and chronic lower respiratory disease accounting for
7805 deaths (ABS, 2022). The health measures put in place to control the spread of
COVID-19 signicantly reduced the spread of droplet-transmitted acute respiratory
infections, such as inuenza and some types of pneumonia, resulting in the second
lowest mortality rate on record from respiratory illness (ABS, 2022).
To date, there have been nearly 13500 deaths in Australia (ABS, 2023) and
2792 deaths in New Zealand attributed to COVID-19 (Ministry of Health, 2023).
422 PHYSICAL EXAMINATION
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UNIT 2
COVID-19 has caused the death of over 7000 males, and 6000 females in Australia
(ABS, 2023). In 2021 it was the 15th highest cause of death (ABS, 2022). Emerging
data and research indicates post-COVID syndrome, also known as post-acute
COVID or long COVID, is increasingly affecting the long-term health of consumers
following an episode of COVID-19 (Augustin et al., 2021).
Of the non-COVID-19 respiratory diseases, asthma and COPD are singled
out here for a brief exploration. Asthma is a signicant global problem affecting
people of all ages, and it is often under-diagnosed and under-treated (WHO, 2022).
In Australia, just under 2.7 million Australians (10.7%) suffered from asthma in
2020–21 (ABS, 2022). The mortality rate for asthma in Aboriginal and Torres Strait
Islander peoples in 2014–18 was 2.2 times that for non-First Nations people (AIHW,
2020). In New Zealand, one in eight people take medication for asthma (Asthma
and Respiratory Foundation NZ, 2020). Hospitalisation is signicantly higher for
Māori (3 times higher), Pasika people (3.2 times higher) and people from the most
deprived households (nearly 3 times higher) when compared with the broader
population (Asthma and Respiratory Foundation NZ, 2020). Other key respiratory
problems for Māori are COPD, bronchiectasis, childhood bronchiolitis and
childhood pneumonia (Asthma and Respiratory Foundation NZ, 2020).
The most signicant risk factors for COPD are being a current daily tobacco
smoker, obesity and being physically inactive (AIHW, 2020), with tobacco use
causing the highest preventable burden for the Australian population (AIHW,
2020). Similarly, in New Zealand most cases of COPD are associated with breathing
tobacco smoke (either by smoking, or indirectly from second-hand smoke) (Health
Navigator New Zealand, 2021). Moreover, the effects of smoking contribute
negatively to the management of asthma and other chronic respiratory disease
symptoms. Of note, however, is the continued decline in smoking in New Zealand,
with daily smoking for Year 10 students down to 1.1% (Asthma and Respiratory
Foundation NZ, 2022b); in Australia, 97% of people aged 14 to 17 have never
smoked, compared with 82% in 2001 (AIHW, 2022b).
The respiratory system is divided into the upper and lower tracts. The upper
respiratory tract comprises the nose, pharynx, larynx and the upper trachea.
The nose and pharynx are discussed in Chapter 11. The lower respiratory tract
is composed of the lower trachea to the lungs. This chapter covers only those
components of the respiratory system that are located in the thorax.
ANATOMY
The respiratory system extends from the nose to the alveoli (Figure 13.1). The normal
air pathway is nose, pharynx, larynx, trachea, main stem bronchus, right and
left main bronchi, lobar/secondary bronchi, segmental/tertiary bronchi, terminal
bronchioles, respiratory bronchioles, alveolar ducts, alveolar sacs and alveoli.
Thorax
The thorax (Figure 13.2) is a cone-shaped structure (narrower at the top and wider at the
bottom) that consists of bones, cartilage and muscles. Of these, the bones are the
supportive structure of the thorax. For the anterior thorax, these bones are the
12 pairs of ribs and the sternum. Posteriorly, there are the 12 thoracic vertebrae
and the spinal column.
Sternum
The sternum, or breastbone, is a at, narrow bone approximately 13cm long. It is
located at the medial line of the anterior chest wall and is divided into three sections:
the manubrium (the upper bone of the sternum that articulates with the clavicles
and the rst pair of ribs), the body, and the xiphoid process (a cartilaginous process
at the base of the sternum that does not articulate with the ribs).
RESPIRATORY 423
A. Anterior view
B. Posterior view
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Parietal pleura
Intercostal
muscle
Nasopharynx
Oropharynx
Laryngopharynx
Rib
Oesophagus
Visceral pleura
Pleural cavity
Lung
Right main stem
bronchus
Diaphragm
Mediastinum
CHAPTER 13
Nasal cavity
Nose
Epiglottis
Larynx
Trachea
Left main
stem bronchus
Secondary
bronchus
Tertiary
bronchus
Terminal
bronchiole
Alveoli
Alveolar
duct
Respiratory
bronchiole
Alveolar sacs
FIGURE 13.1 The respiratory tract
C7
Suprasternal notch
1
2
3
4
5
6
7
Manubrium
Angle of Louis
Costochondral
junction
Body of sternum
8
9
Ribs
Xiphoid
process
Costal
margin
Clavicle
Vertebrosternal ribs
(1–7)
Costal cartilage
False ribs
(8–10)
Floating ribs
(11–12)
FIGURE 13.2 Thorax: rib number is shown on the consumer’s right; intercostal space number is shown on the consumer’s left
10
1
2
3
4
5
6
7
Costal
8
angle
9
11
12
Vertebra prominens
Clavicle
1
2
3
4
5
6
7
8
9
10
11
Ribs
The rst seven pairs of ribs are articulated to the sternum via the costal cartilages
and are called the vertebrosternal or true ribs. The false ribs, or rib pairs 8–10,
articulate with the costal cartilages just above them. The remaining two pairs of
ribs (11 and 12) are termed oating ribs and do not articulate at their anterior
ends. The 10th rib is the lowest rib that can be palpated anteriorly. The 11th rib is
T1
1
2
3
4
5
6
7
8
9
10
11
12
Scapula
Inferior angle
of scapula
424 PHYSICAL EXAMINATION
A. Anterior view
B. Posterior view
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palpated on the lateral thorax, and the 12th rib is palpated on the posterior thorax.
All ribs articulate posteriorly to the vertebral column. When a rib is palpated, the
costal cartilage cannot be distinguished from the rib itself (
Figure 13.2).
UNIT 2
Intercostal spaces
Each area between the ribs is called an intercostal space (ICS). There are 11 ICSs.
CLINICAL REASONING
Practice tip: Counting anterior intercostal spaces
Use the angle of Louis as a landmark for identifying the rib number. Count the ribs in
the midclavicular line. Each ICS is named for the number of the rib directly above it. For
example, the space between the third and fourth ribs would be called the third ICS.
Lungs
The lungs are cone-shaped organs that ll the lateral chamber of the thoracic
cavity. The lower outer surface of each lung is concave where it meets the convex
diaphragm. Likewise, the medial aspect is concave to allow room for the heart, with
the left lung having a more pronounced concavity (cardiac notch). The lungs lie
against the ribs anteriorly and posteriorly.
The right lung is broader than the left lung because of the position of the heart.
Inferiorly, the right lung is about 2.5cm shorter than the left lung because of the
upward displacement of the diaphragm by the liver. The right lung consists of three
lobes (upper, middle and lower); the left lung has two lobes (upper and lower). In the
lung, the
apex denotes the top of the lung; the base refers to the bottom of the
lung. Anteriorly, the apices of the lung extend 2.5 to 4cm superior to the inner
third of the clavicles, and posteriorly, the apices lie near the T1 process. On deep
inspiration posteriorly, the lower lung border extends to the level of T12, and to
T10 on deep expiration. The anterior inferior border of the lungs is at the sixth
rib at the
the clavicle) and at the eighth rib at the
midclavicular line (MCL: vertical line drawn from the midpoint of
midaxillary line (MAL: vertical line
drawn from the apex of the axilla and lying midway between the anterior and the
posterior axillary lines) (see Figure 13.3).
Cardiac notch
RUL
RML
RLL
FIGURE 13.3 Lungs: RUL = right upper lobe; RML = right middle lobe; RLL = right lower lobe; LUL = left upper lobe; LLL = left lower lobe
LUL
Apex
LLL
Clavicle
Base
LUL
LLL
RUL
RLL
T10
(expiration)
T12
(inspiration)
RESPIRATORY 425
A. Anterior view
B. Posterior view
C. Right lateral view
D. Left lateral view
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The lobes of the right and left lungs are divided by grooves called ssures. It is
important to know the locations of the ssures to describe clinical ndings.
Figure 13.4
illustrates the right oblique (or diagonal) ssure, the right horizontal ssure and the
left oblique (or diagonal) ssure.
CLINICAL REASONING
Practice tip: Thoracic anatomic topography
Additional landmarks that are useful when describing assessment ndings are:
> Anterior axillary line – vertical line drawn from the origin of the anterior axillary fold and
along the anterolateral aspect of the thorax
> Midspinal (vertebral) line – vertical line drawn from the midpoint of the spinous process
> Midsternal line – vertical line drawn from the midpoint of the sternum
> Posterior axillary line – vertical line drawn from the posterior axillary fold
> Scapular line (left and right) – vertical line drawn from the inferior angle of the scapula.
Take a look at
anatomical locations and structures they showcase. For example, the anterior axillary line
locates the mid thorax (left lower lung) and commences from the mid underarm.
Figure 13.5. Locate each of the above imaginary lines and note the
CHAPTER 13
Horizontal fissure
5th rib at
midaxillary line
Right
oblique
fissure
5th rib at
midaxillary line
Spinous
process
of T3
RLL
RUL
RML
RUL
RLL
4th rib at
right sternal border
LUL
LLL
Right oblique
fissure
Right
horizontal fissure
4th rib
RML
6th rib at
midclavicular
line
5th rib at
midaxillary line
Left oblique
fissure
6th rib at
midclavicular line
Left oblique
fissure
Left oblique
fissure
6th rib at
midclavicular
line
LUL
LLL
LUL
Spinous process of T3
RUL
RLL
LLL
Right oblique
fissure
Spinous
process
of T3
FIGURE 13.4 Lung ssures
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