Assessment: Thorax and Lung

  1. Assess patient for risk factors for respiratory disorders (e.g., smoking, environmental exposure to pollutants or radiation, and family history of respiratory disorders).
  2. Assess patient for signs and symptoms of respiratory disorders (e.g., cough, sputum production, hemoptysis, chest pain, shortness of breath, orthopnea, dyspnea, activity intolerance, and recurrence of pneumonia or bronchitis).
  3. Posterior thorax: Inspect for shape, deformities, spinal position, slope of ribs, and intercostal retractions on inspiration and bulges on expiration. Also determine rate and rhythm of breathing.
  4. Consider palpation of posterior chest wall, costal spaces, and intercostal spaces. Palpate any mass or swollen area for size, shape, and other characteristics.
  5. Consider palpation for chest excursion. At tenth rib, place thumbs along spinal processes about two inches (5 cm) apart. Let palms rest lightly on posterolateral surfaces with fingers pointing laterally. Press hands toward patient's spine to form small skinfold between thumbs. After exhalation, have patient take deep breath. Note thumb and chest wall movement, which should be symmetrical.
  6. Ask patient to fold arms forward across chest. Consider percussion of the posterior chest wall, moving from side to side and top to bottom, following the palpation pattern. Using indirect percussion, compare percussion notes bilaterally for all lung lobes.
  7. Auscultate breath sounds with stethoscope diaphragm (for adult) firmly on chest wall over intercostal spaces. Have patient take slow deep breaths with the mouth slightly open. Using the palpation pattern, listen to inspiration and expiration at each location; compare breath sounds bilaterally. If sounds are faint, have patient breathe more deeply temporarily.
  8. Lateral thorax: With patient's arms raised, inspect chest wall for same characteristics as reviewed for posterior chest.
  9. Auscultate lateral thorax as stated above. Consider systematic palpation and percussion of the lateral thorax, using the same techniques as on the posterior thorax, except for excursion assessment.
  10. Anterior thorax: Inspect accessory muscles of breathing: sternocleidomastoid, trapezius, and abdominal muscles. Note effort to breathe.
  11. Inspect width of costal angle, which is normally larger than 90 degrees.
  12. Observe the patient's breathing pattern, noting symmetry and degree of chest wall and abdominal movement. Assess respiratory rate and rhythm, if not done earlier.
  13. Consider systematic palpation of the anterior thoracic muscles and ribs for lumps, masses, tenderness, or unusual movement.
  14. Consider palpation for anterior chest excursion. Place hands over each lateral rib cage, with thumbs about two inches (5 cm) apart and angled along each costal margin. As patient inhales deeply, thumbs should move apart symmetrically.
  15. Consider percussion of the anterior thorax between intercostal spaces with patient lying or sitting. Begin above clavicles; move across and then down, following the palpation pattern.
  16. With patient sitting, auscultate anterior thorax, following the palpation pattern. If adventitious sounds are heard, have patient cough. Then listen again.
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