Transcript Thorax and Abdomen

Thorax and Abdomen
Orthopedic Assessment III – Head,
Spine, and Trunk with Lab
PET 5609C
Clinical Anatomy
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Thorax – bone cavity
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Formed by 12 pairs of ribs that join posteriorly with the
thoracic spine and anteriorly with the sternum
Thoracic Cavity:
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Lined with a thin layer of tissue (pleura)
One lung in each thoracic cavity
Mediastinum is between the chest cavity
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Heart, Aorta, Superior and Inferior Vena Cava, Trachea, Major
Bronchi, and Esophagus
Spinal cord – protected by vertebral column
Clinical Anatomy
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Muscles of Inspiration:
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Diaphragm:
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Separates thoracic and
abdominal activities
Innervation: phrenic nerve
Inhalation – diaphragm
contracts enlarging the
thoracic cavity and
reducing intra-thoracic
pressure (air drawn into
lungs)
Exhalation – diaphragm
relaxes and air is exhaled
by elastic recoil of the lungs
Clinical Anatomy
Clinical Anatomy

Muscles of Inspiration:
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Intercostal muscles:
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External intercostal muscles: (outside of the ribcage)
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Internal intercostal muscles: (inside the ribcage)
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Depress the ribs decreasing the transverse dimensions of the
thoracic cavity (aid in forced expiration)
Scalene muscles:
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Elevate the ribs and expand the transverse dimensions of the
thoracic cavity (aid in quiet and forced inhalation)
Elevate the 1st and 2nd ribs
SCM, trapezius, serratus anterior, pectoralis
major/minor and latissimus dorsi (secondary muscles)
Muscles of Expiration:
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Abdominal muscles (rectus abdominis,
internal/external obliques, transverse abdominis
Clinical Anatomy
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Respiratory Tract Anatomy:
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Trachea:
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Pleura:
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Connects larynx to 2 principle bronchi
Left bronchus → 2 segmental bronchi (2 lobes)
Right bronchus → 3 segmental bronchi (3 lobes)
Parietal pleura – lines thoracic wall
Visceral pleura – surrounds lungs
Alveoli:
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Terminal branches of bronchioles
Gas exchange
Capillary system → blood exchanged (pulmonary arteries and
veins)
Heart
Chamber
Function
Right Atrium
Receives deoxygenated blood via:
Superior vena cava (head, neck, upper extremities)
Inferior vena cava (trunk and lower extremities)
Role: Delivers blood to right ventricle
Right Ventricle
Receives deoxygenated blood from right atrium
Role: Delivers blood to lungs via left and right pulmonary
arteries
Left Atrium
Receives oxygenated blood from lungs via right and left
pulmonary veins
Role: Delivers blood to left ventricle
Left Ventricle
Delivers oxygenated blood through aortic valve to
ascending aorta
Clinical Anatomy
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Digestive Tract Anatomy:
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Esophagus:
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Small intestine:
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Duodenum, jejunum, ileum
Large intestine:
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Carries food/liquid to stomach
Cecum, ascending colon, transverse colon,
descending colon, sigmoid colon
Rectum and Anus
Clinical Anatomy
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Lymphatic Organ
Anatomy:
 Spleen:
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Left upper quadrant (level of
9th-11th ribs)
Solid organ
Function:
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Produce and destroy red
blood cells
Blood reservoir
Increased risk of injury →
mononucleosis
Clinical Anatomy
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Urinary Tract Anatomy:
 Kidneys:
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Filter blood
Regulate electrolyte levels:
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Maintain balance of water, sodium, potassium
Location:
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Posterior part of the abdominal cavity: (level of T12 – L3
vertebrae)
 Right kidney: sits below the diaphragm and posterior to the
liver; sits slightly lower than left kidney
 Left kidney: sits below the diaphragm and posterior to the
spleen
 Note: Lower portion of kidneys susceptible to trauma
(unprotected by ribs)
Clinical Anatomy
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Urinary Tract Anatomy:
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Ureters:
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Muscular ducts that propel urine from the kidneys to the urinary
bladder
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Urinary Bladder:
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Length: 10-12 inches (adults)
Solid, muscular, and elastic organ
Collects urine excreted by the kidneys
Urine enters the bladder via the ureters and exits by urethra
Urethra:
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Tube connects urinary bladder to outside the body
excretory function in both sexes (pass urine); reproductive
function in males (passage for semen)
Clinical Anatomy
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Reproductive Tract Anatomy:
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Testes:
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Epididymis:
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Produce estrogen and progesterone and house reproductive
eggs
Fallopian Tubes:
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Coiled tube on posterior aspect of testes (stores sperm)
Ovaries:
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Produce sperm and male sex hormones (testosterone)
Tubules lead from ovaries to uterus
Uterus:
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Accepts the fertilized ovum
Clinical Evaluation
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Anatomy:
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Abdominal cavity
separated from the
thorax by the
diaphragm
Lined with a membrane
(Peritoneum)
Lower portion of
abdominal cavity:
(Pelvic region)
Surrounded by pelvis,
vertebrae, and sacrum
Clinical Evaluation
Upper Right Quadrant
Liver
Kidney
Pancreas
Lung
Upper Left Quadrant
Heart, Lung
Spleen
Kidney
Stomach
Lower Right Quadrant
Appendix
Ureter
Bladder
Colon
Gonads
Lower Left Quadrant
Ureter
Bladder
Colon
Gonads
Clinical Evaluation
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History:
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Location of Pain:
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Onset of Symptoms:
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Musculoskeletal pain → ribs, costal cartilage, abdominal
muscles (tender at injury site)
Injury to internal organs → diffuse pain; referred pain sites
(Kehr’s sign)
Gradual (internal bleeding can accumulate within cavity)
Pain ↑ with breathing (rib, abdominal injury)
Mechanism of Injury:
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Direct blow (thoracic, abdominal, pelvic injuries)
Clinical Evaluation
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History:
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Symptoms:
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Medical History:
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Pain, difficulty breathing
Diffuse abdominal pain
Nausea, dizziness
Vomiting of blood, blood in urine/stool
Not common (acute injury)
Exercise-induced asthma
Illnesses (mononucleosis)
General Medical Health:
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Medications
Clinical Evaluation
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Inspection:
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Start → observe
patient’s posture
Throat:
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Inspection:
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Rate, respiration rate,
depth, quality
Nail beds:
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Capillary refill (cyanosis)
Muscle tone
Discoloration of skin:
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Breathing pattern:
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Position of trachea and
larynx
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Vomiting:
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Contusions, wounds,
abrasion
Presence of blood
Hematuria
Clinical Evaluation
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Inspection:
 Auscultation:
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Lungs:
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Inhalation – smooth
unobstructed sound
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Absence:
pneumothorax,
collapsed lung
Rales: pneumonia
Abdomen:
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Gurgling noises
(peristalsis)
Clinical Evaluation
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Palpation:
 Sternum:
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Manubrium, body,
xiphoid process
Costal cartilage and
ribs:
Palpate anterior to
posterior
 Pain, crepitus,
deformity
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Clinical Evaluation
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Palpation:
 Spleen:
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Palpate for enlarged
spleen under left rib cage
Have patient raise arms
above head
Clinical Evaluation
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Palpation:
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Kidneys:
Location → under
posterolateral
portion of rib cage
 Right kidney rests
more inferior than
left
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Clinical Evaluation
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Palpation: Liver
 Method 1:
Place your fingers just
below the costal margin
and press firmly
 Ask the patient to take a
deep breath
 May feel the edge of the
liver press against or
slide under your hand
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Normal liver is not
tender
Clinical Evaluation
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Palpation: Liver
 Method 2:
Hands "hooked"
around the costal
margin from above
 Instruct patient to
breath deeply to force
the liver down toward
your fingers
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Clinical Evaluation
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Palpation: McBurney’s
Point
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Location → one-third of
way between right ASIS
and naval
Tenderness → may
indicate acute
appendicitis
Clinical Evaluation
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Palpation: Abdomen
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Rigidity:
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Occurs secondary to
muscle guarding or
blood accumulation
Indication of internal
injury
Rebound Tenderness:
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Tests for peritoneal
irritation.
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Palpate deeply and
then quickly release
pressure
↑ pain = peritoneal
irritation
Clinical Evaluation
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Palpation: Abdomen
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Tissue density: Percussion
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Patient position: hook-lying
Examiner: Lightly places one hand
over abdomen (palm down);
Index/middle fingers of opposite
hand tap the DIP joints
Findings: (normal)
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Solid organs have a dull thump
Hollow organs more resonant sound
Findings: (positive)
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Hard, solid sounding echo over
areas that should sound hollow
Internal bleeding
Clinical Evaluation
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Palpation: Percussion
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Hollow Organs
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Allow materials to pass
through them (stomach,
large intestine, small
intestine, pancreas) or
act as “holding tanks”
(gall bladder and urinary
bladder)
Less risk for injury when
empty
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Palpation: Percussion
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Solid Organs:
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Significant blood supply
Liver, Spleen, Pancreas,
Kidney, Ovaries, Testes
Higher risk of injury
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Bruising
Tearing
Clinical Evaluation
Quadrant Pain:
Upper
Lower
Right
Left
Liver: Pain associated
with cholecystitis or liver
laceration
Gall bladder: Pain
without trauma indicates
gall bladder disease
Spleen: Rigidity under
the last several ribs
Appendix: Rebound
tenderness indicates
appendicitis
Colon: Colitis or
diverticulitis may cause
pain
Pelvic inflammation:
Diffuse tenderness
Colon: Colitis or
diverticulitis may cause
pain
Pelvic inflammation:
Diffuse tenderness
Clinical Evaluation
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Vital Signs:
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Heart Rate:
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Pulse:
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Normal pulse is 60-100 beats per
minute
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Athletes tend to have a slower pulse
than non athletes (well-conditioned
strong heart)
Normal pulse is 60-100 beats per
minute
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Regular / Irregular
Strong / Weak
Athletes tend to have a slower pulse
than non athletes (40-60 bpm)
Abnormal:
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Tacchycardia: > 100 bpm
Bradycardia: < 60 bpm
Clinical Evaluation
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Vital Signs: Blood Pressure
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Patient position:
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Seated or supine
Procedure:
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Cuff secured over upper arm
Stethoscope placed over brachial
artery
Inflate cuff to 180-200 mm Hg
Air slowly released
Note point at which 1st pulse
sound is heard
Note point at which last pulse
sound is heard
Clinical Evaluation
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Vital Signs: Blood Pressure
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Affected by:
Decrease in blood volume (severe bleeding or
dehydration) – Hypovolemic shock
 Decreased capacity of vessels (shock)
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Rapid/weak pulse; ↓ BP
Decreased ability of heart to pump blood
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↓ nutrients/oxygen to organs of body (anoxia)
Clinical Evaluation
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Vital Signs: Respiratory
Rate
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Normal: 12 – 20 bpm
Abnormal:
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Rapid, shallow breaths:
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Deep, quick breaths:
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Internal injury
Shock
Pulmonary instruction
Asthma
Noisy, raspy breaths:
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Airway obstruction
Clinical Evaluation
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Rib Fractures:
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Most common injured:
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5th-9th ribs (anterior and lateral portions)
History:
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Onset: acute (single traumatic blow)
Pain: over fracture site
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↑ pain with deep inspirations, coughing, sneezing, movement of
torso
MOI:
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Force (anteroposterior direction) – outward displacement
Force (lateral side) – inward displacement
 Internal injury (i.e. lungs)
Clinical Evaluation
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Rib Fractures:
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Inspection:
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Splinting posture:
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Discoloration / swelling
Shallow, rapid respirations (minimize chest movement)
Palpation:
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Holding the painful area to limit chest wall movement during
inspiration
Point tenderness, crepitus, possible deformity
Functional Tests:
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Movement of torso causes pain
↑ pain with deep respiration, coughing, sneezing
Clinical Evaluation
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Rib Fractures:
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Stress Fractures:
Rowing, swimming, golf
 Posterolateral portion of 4th-9th ribs
 Causes:
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Overtraining, sudden increases in training
Improper biomechanics
Special Tests:
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Rib compression test:
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Contraindicated in presence of obvious fracture/lung
trauma
Clinical Evaluation
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Lateral Rib Compression
Test:
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Test position:
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Action:
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Subject supine
Examiner compresses the
lateral aspect of the rib cage
then quickly releases
Positive finding:
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Pain with compression or
release of pressure indicates
possible rib fracture,
contusion, or costochondral
separation
Clinical Evaluation
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Anterior/Posterior Rib
Compression Test:
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Test position:
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Action:
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Subject supine
Compress rib cage anterior to
posterior and quickly release
Positive test:
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Pain with compression or
release of pressure indicates
possible fracture, rib
contusion, costochondral
separation
Clinical Evaluation
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Costochondral Injury:
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MOI:
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Overstretching the
costochondral junction
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Hyperflexion
Horizontal abduction
“Snap” or “pop” at time of
injury
Symptoms:
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Anterior pain (cartilage
junction)
↑ pain with deep breathing,
coughing, sneezing
Clinical Evaluation
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Pneumothorax:
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Accumulation of air in pleural activity
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Spontaneous pneumothorax:
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Diagnosis dependent on signs/symptoms – rare condition
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Contributing Factors:
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Family history, tall and thin body build
Sports-related spontaneous pneumothorax – documented in
weight lifting, football, jogging
Primary spontaneous pneumothorax:
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Chest pain, dyspnea, diminished breath sounds
Chest pain – usually localized to the side of the affected lung
 Can radiate to shoulder, neck, back
Primary cause: Bleb (imperfection in the lining of the lung)
bursts causing lung to deflate
Tall thin men (ages 20-40)
Secondary spontaneous pneumothorax:
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Chronic obstructive pulmonary disease (COPD)
Clinical Evaluation
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Pneumothorax:
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Tension pneumothorax:
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One-way valve is created from
either blunt or penetrating
trauma
Air can enter, CANNOT leave
the pleural space
↑ Intrathoracic pressure will
collapse the lung and ↑ pressure
on mediastinum
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Pressure will eventually
collapse superior and inferior
vena cava (loss of venous
return)
Clinical Evaluation
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Pneumothorax:
 Clinical Signs:
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Palpation:
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Apprehension / Agitation
Cyanosis
Diminished breath sounds
Distended neck veins /
Tracheal deviation
Trauma induced – point
tenderness
Vital Signs:
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Labored, shallow respirations
BP drops rapidly
Right tension pneumothorax
Clinical Evaluation
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Hemothorax:
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Blood enters the pleural space
Massive Hemothorax – at least
1500cc of blood loss into thoracic
cavity
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Penetrating injury
Can occur from blunt trauma
Blood accumulates → lung on the
affected side is compressed
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Mediastinum may shift away from
hemothorax
Inferior and superior vena cava and
contralateral lung may become
compressed
Clinical Evaluation
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Hemothorax:
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Clinical signs/symptoms:
Produced by hypovolemia
and respiratory
compromise
 Anxiety, apprehension
 Symptoms of hypovolemic
shock
 Decreased breath sounds or
absence at injury site
 Flat neck veins
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Clinical Evaluation
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Spleen Injury:
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History:
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Acute (symptoms may take a few hours to develop)
Pain:
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Predisposing conditions:
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Upper left quadrant
Kehr’s sign – pain in upper left shoulder
Mononucleosis:
 ↑ mass, ↓ elasticity
Inspection:
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Impact site – contusion
Nausea and vomiting
Clinical Evaluation
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Spleen Injury:
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Palpation:
Cold and clammy skin (shock)
 Pont tenderness
 Rebound tenderness
 Distention in upper left quadrant
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Functional Tests:
Kerh’s sign
 Low blood pressure
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Clinical Evaluation
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Kidney Pathologies:
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Contused/Lacerated Kidney:
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History:
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Onset: acute
Pain: posterolateral portion of upper lumbar and lower
thoracic region
MOI: blunt trauma or penetrating injury to kidney
Inspection:
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Contusion or laceration
Hematuria:
 Severe bleeding → noticeable blood
 Laboratory analysis needed
Signs/symptoms of shock
Clinical Evaluation
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Kidney Pathologies:
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Palpation:
Point tenderness
 Abdominal rigidity
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Functional Testing:
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Pain with urination
Laboratory Testing:
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Hematuria
Clinical Evaluation
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Kidney Stones:
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Collection of incomplete
kidney filtration
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Causes:
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Crystals of uric acid, calcium
1mm – 2.5 cm
Family history, stress, diet
Signs:
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Pain with urination
Pain (stone passed from
bladder through urethra)
Clinical Evaluation
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Urinary Tract Infections:
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Bacterial infections of bladder or urethra
Similar signs/symptoms of kidney stones
Dysuria → frequent need to urinate
Hematuria (abnormal urine color)
Urethritis:
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Inflammation of urethra
Causes: chlamydia, gonorrhea, syphilis
More common in males
Clinical Evaluation
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Appendicitis and Appendix
Rupture: Anatomy
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Location: Lower Right
Quadrant of Abdomen
Elongated tube connected to
the cecum (pouch-like
structure of the colon)
Function of the human
appendix is unknown
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Considered to be a remnant of
a portion of the digestive tract
which was once more
functional and is now in the
process of evolutionary
regression
Clinical Evaluation
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Appendicitis:
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Cause:
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Inflammation caused by fecal
obstruction, lymph swelling,
tumor
High incidence in males
(ages 15 – 25)
If bursts can bleed into peritoneal
cavity and cause bacterial
infection
Signs and Symptoms:
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Mild to severe pain in lower
abdomen
Nausea, vomiting, fever,
cramping, abdominal rigidity,
point tenderness
McBurney’s Point – between
ASIS and umbilicus
Clinical Evaluation
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Hollow Organ Rupture:
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Blunt trauma (non-rupture): able to absorb forces
(deform/return to original shape without permanent
injury)
Rupture:
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Can be fatal (secondary to hemorrhage, peritoneal
contamination)
MOI and Signs/Symptoms:
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Blow to abdomen
Abdominal pain, possible nausea
Palpation reveals guarding, rigidity, tenderness (point, rebound)
Bowel sounds are absent (auscultation)
Blood in stool
Clinical Evaluation
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Gastritis:
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Inflammation of stomach lining
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Causes:
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Esophageal Reflux:
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Backflow of gastric juices into esophagus
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Aspirin or anti-inflammatory medications
Alcohol
Infection, bile entering stomach
Heartburn, regurgitation of stomach acid
Ulcer-like pain
Intestinal Ulcers:
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Irritation of duodenum (peptic ulcer)
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Abdominal pain, nausea, vomiting, dark stools, fatigue
Causes:
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Bacteria
Long-term use of aspirin or anti-inflammatory medications
Clinical Evaluation
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Dyspepsia:
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Pain in upper abdomen
Common causes:
Gastroesophageal reflux
disease (GERD), stomach
ulcers
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GERD – stomach acid
splashes out of upper valve
onto walls of esophagus
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Burning pain in mid-upper
abdomen / heartburn
Stomach Ulcers – wounds in
lining of stomach
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Common causes: Stress,
virus, diet
Potential for bleeding if
ulcers go untreated (open
wounds)
Clinical Evaluation
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Colitis:
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Inflammation of the large intestine
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Symptoms:
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Causes:
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Disease, irritation of bowel, ulcers, ischemia, bacteria, stress
Regional Enteritis (Crohn’s Disease):
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Frequent diarrhea
Abdominal pain, increased bowel sounds, fever, painful defecation,
nausea, vomiting
Affects the ileum
Produces LRQ pain, cramping
Irritable Bowel Syndrome:
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Alters motility of the muscles of large intestine
Alternating bouts of diarrhea and constipation
Abdominal pain
Gas build-up, nausea, vomiting
Clinical Evaluation
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Testicular Contusion:
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MOI: Direct blow
Inspection:
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Patient instructed to inspect for
normal size/consistency
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Ruptured testicle – soft,
inconsistent texture
Testicular Torsion:
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Spermatic cord and testicle
twisted within scrotum
Symptoms:
Acute testicular pain, swelling,
tenderness
Note: Immediate referral needed
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Clinical Evaluation
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Menstrual Irregularities: (associated with
physical activity)
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Female Athlete Triad:
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Combination:
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Disordered eating
Amenorrhea
Osteoporosis
Disorder that often goes unrecognized
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Lost bone mineral density
Premature osteoporotic fractures
Lost bone mineral density may never be regained
Clinical Evaluation
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Female Athlete Triad:
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Disordered Eating:
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Anorexia, Bulimia, ENDOS
Amenorrhea:
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Related to athlete training/weight fluctuation is caused by
changes in the hypothalamus
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Result: Decreased levels of Estrogen
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Primary Amenorrhea:
 No spontaneous uterine bleeding:
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By the age of 14 without development of 20 sexual
characteristics
By the age of 16 with otherwise normal development
Clinical Evaluation

Female Athlete Triad:

Amenorrhea:


Secondary Amenorrhea:
 6-month absence of menstrual bleeding in a woman with
primary regular menses
 12-month absence with previous oligomenorrhea
Osteoporosis:


Loss of bone mineral density and inadequate formation of
bone
Premature osteoporosis:
 Risk for stress fractures
 Fx of hip, vertebral column