med 1.4 pe of the chest, lungs, breast, and axilla.pdf

TRANSCRIBED BY: TED, ROBIN, BARNEY, MARSHALL, LILY

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Sonia Comia, M.D. | Alfredo Guzman, M.D. | Elvic Tengco, M.D.

El Funny how sometimes you just find things. Tracy McConnell, How I Met Your Mother Paulo Coelho

Physical Examination of the Chest, Lungs, Breast, and Axilla

1.4 16 June

2014

CHEST AND THORAX THORAX

A cage of bone, cartilage, and muscle that is capable of movement as the lungs expand

Borders: o Anteriorly: sternum, manubrium, xiphoid process o Laterally: 12 pairs of ribs o Posteriorly: 12 thoracic vertebrae

Chest abnormalities should be described in 2 dimensions: o Along the vertical axis o Around the circumference of the chest

THORAX MAPPING

To make vertical locations 1. Count the ribs and interspaces 2. Use the Angle of Louis as a guide 3. Place your finger in the hollow curve of suprasternal notch 4. Move your finger down about 5cm to the horizontal bony ridge

joining the manubrium to the body of the sternum 5. Move your finger laterally and find the adjacent 2nd rib and

costal cartilage 6. Using two fingers, you can walk down the interspaces, one

space at a time, on an oblique line

THORACIC LANDMARKS

ALONG THE VERTICAL AXIS

11th rib Cartilaginous tip can usually be felt laterally

12th rib May be felt posteriorly Possible starting point for counting ribs and interspaces With the fingers of one hand, press in and up against the lower border of the 12th rib, then walk up the interspaces or follow a more oblique line up and around to the front of the chest

Scapula Inferior tip lies at the level of the 7th rib or interspace

Vertebrae Spinous processes are useful anatomic landmarks

C7 Vertebra is the most protruding process when the neck is flexed forward

C7 and T1 Equally prominent

VERTICAL LINES AROUND THE CIRCUMFERENCE OF THE

TOPIC OUTLINE I. Chest and Thorax

A. Thorax B. Lungs C. Trachea and Major Bronchi (Tracheobroncial

Tree) D. The Pleurae E. Anatomic Landmarks

II. Breathing A. Chemical and Neurologic Control of

Respiration B. Breathing Patterns

III. The Health History A. Chest Pain B. Dyspnea C. Wheezes D. Cough E. Summary

IV. Past Medical History

V. Family History VI. Personal & Social History VII. Examination of the Thorax (Chest) & Lungs

A. Initial Survey of Respiration & the Thorax B. Inspection C. Palpation D. Percussion E. Auscultation

VIII. Summary of Examination: Chest and Lungs IX. Physical Examination of the Breast and Axillae

A. Female Breast B. Male Breast C. Lymphatics D. Breast Lump or Mass E. Breast Pain or Discomfort F. Nipple Discharge G. Modifiable vs. Non-modifiable Risk Factors H. Visible Signs of Breast Cancer I. Summary of Breast Cancer Risk Factors

X. Examination of the Axilla A. Common Breast Masses


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Physical Examination

of the Chest, Lungs,

Breast, and Axilla

CHEST

Midsternal and Vertebral Lines

Midclavicular Line

Anterior and Posterior Axillary Lines

Midaxillary Line

Scapular Line

LUNGS

Paired, but not symmetric o Right: 3 lobes (upper + middle + lower) o Left: 2 lobes (upper + lower + lingula)

The lingula of the left upper lobe corresponds to the right middle lobe

Each lung has a major fissure (oblique) which divides the upper and lower portions

The right lung has a lesser horizontal fissure

Each lobe consists of blood vessels, lymphatics, nerves, and an alveolar duct connecting with the alveoli

The anterior exam is mainly for the upper and middle lobes

The posterior exam will cover the upper and lower lobes

BORDERS AND LANDMARKS

LUNGS

Anterior Apex rises about 2cm to 4cm above the inner third of the clavicle Lower border crosses the 6th rib at the midclavicular line and the 8th rib at the midaxillary line

Posterior Tipe lies at the level of T1 Anatomic lower border lies at about the level of T10 spinous process Ausculatatory lower border lies only up to the 9th ICS, which is also the percussion border

FISSURES

Oblique (Major) FIssure

Divides each lung roughly in half May be approximated by a string that runs from the T3 spinous process obliquely down and arounf the chest to the 6th rib at the midclavicualr line

Horizontal (Minor) Fissure

Further divides the right lung Anteriorly, it runs close to the 4th rib and meets the oblique fissure in the midaxillary line near the 5th rib

LOCATIONS ON THE CHEST

Supraclavicular above clavicle

Infraclavicular below clavicles Interscapular between scapulae Infrascapular below scapular Bases of the lungs lowermost portions

TRACHEA AND MAJOR BRONCHI

(TRACHEOBRONCHIAL TREE)

Tubular system that provides pathway for air to move from the upper airway to farthest alveoli

Breath sounds over the trachea have a different quality than breath sounds over the lung parenchyma

10cm-11cm long, and 2cm in diameter

Anterior to the esophagus and posterior to the isthmus of the thyroid

The trachea bifurcates into its mainstream bronchi at the levels of the sternal angle anteriorly (level of the carina) and the T4 spinous process posteriorly o Right bronchus: wider, shorter, and more vertical o During intubation, the tube will most likely go to the right

bronchus, so you have to pull it a few centimeters to make sure that it is in the trachea.

Main bronchi are divided into 3 on the right, and 2 on the left

THE PLURAE

Visceral pleura o Serous membranes that cover the outer surface of each lung

Parietal pleura o Line the upper rib cage and upper surface of the diaphragm

Pleural space is the potential space between visceral and parietal pleurae

Three major spaces in the chest o Right pleural cavity o Left pleural cavity o Mediastinum

ANATOMIC LANDMARKS

Nipples

Manubriosternal junction (Angle of Louis)

Suprasternal notch

Costal angle

Vertebral prominence

Clavicles

BREATHING CHEMICAL AND NEUROLOGIC CONTROL OF RESPIRATION

Purpose: to keep the body adequately supplied with O2 and to protect it from excess CO2

Involves movement of air back and forth from alveoli to outside (Ventilation)

Gas exchange across the alveolar-pulmonary capillary membranes (diffusion and perfusion), and circulatory system transport of O2 to, and CO2 from, the peripheral tissues

Chemoreceptors in the medulla oblongata: sensitive to changes in [H] ion in the blood and the spinal fluid

Chemoreceptors in the carotid bodies: respond to changes in arterial O2 and CO2 levels

Both of these receptors respond by sending signals to the respiratory center in the medulla oblongata

Nerve impulses from here are transmitted ot two subcenters in the pons, which regulate the respiratory muscles

Excess level of CO2 stimulate the rate and depth of respiration

MUSCLES OF RESPIRATION

MUSCLES DESCRIPTION

Diaphragm Dome-shaped Primary muscle of inspiration

External Intercostal Increase anteroposterior chest diameter during inspiration

Internal Intercostal Decrease transverse diameter during expration

Ribcage and neck muscles (parasternals and scalenes)

Expand thorax during inspiration

Sternocleidomastoid and trapezius

Contribute to respiratory movements

1. During inspiration, as these muscles contract, the thorax expands 2. Intrathoracic pressure decreases, drawing air through the

tracheobronchial tree into the alveoli, or distal air sacs, and expanding the lungs


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Breast, and Axilla

3. Oxygen diffuses into the blood of adjacent pulmonary capillaries while carbon dioxide diffuses from the blood into the alveoli

4. After inspiratory effort stops, the expiratory phase begins 5. The chest wall and lungs recoil, the diaphragm relaxes and rises

passively, air flows outward, and the chest and abdomen return to their resting positions

During exercise and in certain diseases, extra work is required to breathe, and accessory muscles join the inspiratory effort

The sternocleidomastoids are the most important of these muscles.

BREATHING PATTERNS

THE HEALTH HISTORY

Common or concerning symptoms:

Chest pain

Dyspnea

Wheezes

Cough

Blood-streaked sputum (hemoptysis)

CHEST PAIN

Your initial questions should be as broad as possible. Do you have any discomfort or unpleasant feelings in your chest?

As you proceed to the full history, ask the patient to point to where the pain is in the chest

Watch for any gestures as the patient describes the pain

Remember: Lung tissue itself has no pain fibers

Pain in lung conditions such as pneumonia or pulmonary infarction usually arises from inflammation of the adjacent parietal pleura

Muscle strain from prolonged recurrent coughing may also be responsible

The pericardium also has a few pain fibers the pain of pericarditis stems from inflammation of the adjacent parietal pleura

Anxiety is the most frequent cause of chest pain in children; costochondritis is also common

SOURCES OF CHEST PAIN

Myocardium Angina pectoris, myocardial infarction

Pericardium Pericarditis

Aorta Dissecting aortic aneurysm

Trachea and large bronchi Bronchitis

Parietal pleura Pericarditis, pneumonia

Chest wall, including musculoskeletal system and skin

Costochondritis, herpes zoster

Esophagus Reflux esophagitits, esophageal spasm

Extrathoracic structures such as the neck, gallbladder, and stomach

Cervical arthritis, biliary colic, gastritis

DYSPNEA

A non-painful but uncomfortable awareness of breathing that is inappropriate to the level of exertion

Ask Have you had any difficulty breathing?

Find out when the symptom occurs, at rest or with exercise, and how much effort produces onset.

Carefully elicit the timing and setting of dyspnea, any associated symptoms, and relieving or aggravating factors

Anxiety may cause episodic dyspnea during both rest and exercise

10 Ps of Dyspnea o Pneumonia o Pneumothorax o Pulmonary constriction (asthma) o Peanut (foreign body) o Pulmonary embolus o Pericardial tamponade o Pump failure (heart failure) o Peak seekers (high altitude) o Psychogenic

WHEEZES

Musical respiratory sounds that may be audible both to the patient and to others

Wheezing suggests partial airway obstruction from secretions, tissue inflammation, or a foreign body

COUGH

Reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi

Ask whether the cough is dry or produces sputum, or phlegm

Ask patient to describe the volume, color, odor, and consistency of any sputum

COUGH SIGNIFICANCE

Dry, hacking cough Mycoplasmal pneumonia

Productive cough Bronchitis, viral or bacterial pneumonia

Mucoid sputum Translucent, white, or gray

Purulent sputum Yellowish or greenish

Foul-smelling sputum Anaerobic lung abscess

Tenacious sputum Cystic fibrosis

Large volumes of purulent sputum

Bronchiectasis or lung abscess

To help parents quantify volume, a multiple-choice question may be helpful

If possible, ask the patient to cough into a tissue, and then inspect the phlegm and its characteristics

Hemoptysis is the coughing up of blood from the lungs

It may vary from blood-streaked phlegm to frank blood

Assess the volume of blood produced as well as the other sputum attributes

Ask about the related setting and activity and any associated symptoms

Before using the term hemoptysis, try to confirm the source of the bleeding by both history and physical examination

Blood originating in the stomach is usually darker than blood from the respiratory tract and may be mixed with food particles

SUMMARY

CHEST PAIN Onset and Duration: associated with trauma, cough, LRI Associate Symptoms: shallow breathing, fever, uneven chest expansion, cough, radiation of pain Efforts to treat: heat, splinting, medication

DYSPNEA Onset: sudden or gradual; duration Pattern: position most comfortable, number of pillows used related to extent of exercise, certain activities Severity: extent of activity limitation, fatigue with breathing Associated symptoms: pain or discomfort, cough, diaphoresis, ankle edema

COUGH Onset: sudden, gradual, duration Nature of cough: dry, moist, wet, hacking, barking, whooping, bubbling, productive, nonproductive Sputum production: duration, frequency Sputum characteristics: amount, color, odor


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Breast, and Axilla

Pattern: occasional, regular, paroxysmal; related to time of day, weather, activities Severity: tires patients, disrupts sleep Associated symptoms: SOB, chest pain, fever, hoarseness Efforts to Treat: medications and their effectiveness

PAST MEDICAL HISTORY

Thoracic trauma or surgery, hospitalizations for pulmonary disorders

Use of Oxygen or ventilation-assisting devices

Chronic pulmonary diseases: o PTB o Asthma o COPD

Other chronic disorders: o Cardiac o Cancer

Testing: o Allergy o Pulmonary function tests (PFT) o Tuberculin & fungal skin tests o Chest x-ray (CXR)

FAMILY HISTORY

Tuberculosis

Emphysema

Allergy, Asthma, Atopic dermatitis

Malignancy

Cystic fibrosis

PERSONAL & SOCIAL HISTORY

Employment: nature of work, environmental hazards, exposure to chemicals, vapors, dust, pulmonary irritants, use of protective devices, allergens

Home environment : allergens, air conditioners, humidifiers

Tobacco use: type of tobacco, duration , amount, age started, efforts to quit, passive smoke = # # /

Exposure to respiratory infections: influenza, tuberculosis

Nutritional Status: weight loss or obesity

Regional or travel exposures

Hobbies: pigeons or parrots, woodwork, welding

Use of alcohol/illegal drugs

Exercise tolerance

EXAMINATION OF THE THORAX (CHEST) & LUNGS INITIAL SURVEY OF RESPIRATION & THE THORAX

It is helpful to examine the posterior thorax & lungs while the patient is sitting and the anterior thorax and lungs with the patient supine.

Even though you may have already recorded the respiratory rate when you took the vital signs, it is wise to again observe the rate, rhythm, depth, and effort of breathing.

A normal resting adult breathes quietly and regularly about 14-20 times a minute.

Assess the patients color for cyanosis and clubbing o Cyanosis signals hypoxia o Clubbing of the nails can be observed in patients with chronic

obstructive pulmonary disease (COPD) or congenital heart disease

Listen to the patients breathing o Is there any audible wheezing? o If so, where does it fall in the respiratory cycle? o Audible stridor, a high-pitched wheeze, is an ominous sign of

airway obstruction in the larynx or trachea.

Inspect the neck o During inspiration, is there contraction of the SCM or other

accessory muscles, or supraclavicular retraction? o Is the trachea midline? o Inspiratory contraction of the SCM at rest signals severe

difficulty breathing. o Lateral displacement of the trachea in pneumothorax, pleural

effusion, or atelectasis

Observe the shape of the chest

o The (AP) diameter may increase with aging and in patients with COPD

INSPECTION

You have to expose the whole thorax

Patient must remove clothing

From a midline position behind the patient, note the shape of the chest and the way in which it moves, including: o Deformities or asymmetry (note the shape & symmetry of the

chest back & front; AP diameter is < Transverse diameter by half)

o Abnormal retraction of the interspaces during inspiration (retraction in severe asthma, COPD, or upper airway obstruction)

o Impaired respiratory movement on one or both sides or a unilateral lag (or delay) in movement

Condition Observations

Barrel chest Ribs more horizontal, sternal angle more prominent; trachea displaced posteriorly

AP diameter Kyphosis Spine deviated POSTERIORLY Scoliosis Spine deviated LATERALLY Pectus Excavatum (tunnel chest)

Indentation of the lower sternum above the xiphoid process

Note depression in the lower portion of the sternum

Compression of the heart and great vessels may cause murmurs

Pectus Carinatum (pigeon chest)

Prominent sternal protrusion

AP diameter

Costal cartilages adjacent to the protruding sternum are depressed

Watch a patient breath and pay particular attention to: 1. General comfort and breathing pattern of the patient.

Do they appear: o Distressed o Diaphoretic o Labored o Are the breaths regular and deep?

2. Use of accessory muscles of breathing (e.g. scalenes, sternocleidomastoids) as it signifies some element of respiratory difficulty.

3. Color of the patient, in particular around the lips and nail beds.

Watch for cyanosis

Watch for clubbing of the fingertips (oo, yung fingertips nagpaparteeyy!)

CLUBBING Acronym: o C Cyanotic heart diseases o L Lung diseases; Hypoxia, Lung cancer, Bronchiectasis,

Cystic fibrosis o U Ulcerative colitis, Crohns disease o B Biliary cirrhosis o B Birth defect (Harmless) o I Infective Endocarditis o N Neoplasm (especially Hodgkins lymphoma) o G GI malabsorption

Clubbing, when fingernails are viewed from side,

angle of base of nail is >160

o Clubbing can be either: a. Primary

Has a direct cause that is unknown in origin


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Breast, and Axilla

b. Secondary A manifestation of an underlying disease Can be generalized or localized

Generalized Localized

Pulmonary o Cystic Fibrosis o Bronchiectasis

Cardiac o Congenital Cyanotic Heart

Disease

Gastrointestinal o Crohns Disease o Ulcerative Colitis

Miscellaneous o Graves Disease o Thymoma

Hemiplegia

Trauma

4. The position of the px

Those with extreme pulmonary dysfunction will often sit upright

In cases of real distress, they assume the Tripod position: o They will lean forward, resting their hands on their knees

Patient with Emphysema at Tripod Position

5. Breathing through pursed lips, often seen in cases of emphysema.

6. Ability to speak.

The fewer words per breath, the worse the problem 7. Any audible noises associated with breathing wheezing or

gurgling caused by secretions in large airways are audible without auscultation.

8. Note any chest or spine deformities (see images at succeeding text). These may arise as a result of:

Chronic lung disease (e.g. emphysema), congenitally, or acquired.

In any case, they can impair patient's ability to breath normally

9. The direction of abdominal wall movement during inspiration.

Normally, the descent of the diaphragm pushes intra-abdominal contents down and the wall outward.

Paradoxical breathing o In cases of severe diaphragmatic flattening (e.g.

emphysema) or paralysis, the abdominal wall may move inward during inspiration.

o If you suspect this to be the case, place your hand on the patient's abdomen as they breathe, which should accentuate its movement.

In respiratory distress, some of the following may occur: o Accessory muscle use o Nasal flaring o Intercostal retractions o Abdominal paradox

10. Look for prominent chest veins

Especially if the patient also had a raised JVP, as it can occur due to SVC obstruction

11. Note for scars.

This may give an indication of previous operations or procedures.

12. Look at the chest wall movements:

Are they symmetrical, i.e. the same on both sides, or

Is there a difference?

Is there any lag or impairment of respiratory movement?

Condition Observations

Normal

Wider > deep

Lateral diameter > AP diameter

Pectus Excavatum (Funnel chest)

Depression in the lower portion of the sternum

Compression of the heart and great vessels may cause murmurs

Gives chest a somewhat hollowed-out appearance.

The x-ray shows a subtle concave appearance of the lower sternum

Lubog and dibdib mala-funnel

Barrel chest

AP diameter

Normal during infancy

Often accompanies aging and COPD

Mala-barrel and dibdib aka drum and tiyan

Pectus Carinatum (Pigeon Chest)

Anteriorly displaced sternum AP diameter

Costal cartilages adjacent to the protruding sternum are depressed

Matulis and dibdib mala-pigeon

Traumatic Flail Chest

Multiple rib fractures may result in paradoxical movements of the thorax

As descent of the diaphragm decreases intrathoracic P, on inspiration the injured area caves inward; on expiration, it moves outward

Thoracic Kyphoscoliosis

Abnormal spinal curvatures & vertebral rotation

Kyphosis - spine deviated posteriorly


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Breast, and Axilla

Scoliosis spine deviated laterally

Kyphosis

Scoliosis

Others notable chest signs:

Harrisons Sulcus

Depression above costal margin (from rickets & childhood asthma)

Rickety Rosary

Rosary-like formation in Rickets

Obstruction at SVC

Obstruction at IVC

RESPIRATION POSTERIOR

Px sitting

Arms should be folded across the chest

Hands resting on the opposite shoulders o Moves the scapulae partly out of the way and increases

access to the lung fields

ANTERIOR

Then ask the px to lie supine and examine the anterior lung fields

INITIAL SURVERY OF RESPIRATION

Rate, rhythm, depth and effort of breathing

Signs of respiratory difficulty

Color o Pallor deficiency of oxyHb; more associated with anemia

and CV disorders o Cyanosis excess of deoxyHb; associated with CV but more

often with respiratory disorders

Listen to the Pxs breathing Inspect the neck

Trachea

Deviates toward the involved side o Atelectasis o Significant parenchymal or pleural fibrosis

Deviates toward the opposite side

o Thyroid Enlargement o Pleural Effusion o Tension Pneumothorax o Tumors

Diaphragm o Moves downward during inspiration

SCM and Traps (Accessory Muscles) o prominent in patients with moderate respiratory distress

Tachypnea mild respiratory distress Shoulder shrugging severe respiratory distress Smell of breath:

Halitosis significant for abscesses, regurgitation, achalasia

Uremic fetor (smells like urine)

Fruity odor in DKA Ammoniacal breath in liver disease/failure

MODES OF RESPIRATION

Modes of Respiration

Observations

Thoracic (Costal) Use of intercostal muscle

Diaphragmatic

Movement of diaphragm responding to intrathoracic P

Abdominal Contraction of diaphragm & interplay of abdominal muscles resulting to expansion & recoil of abdominal walls

During labored breathing Paradoxic Occurs when a negative intrathoracic

P is transmitted to the abdomen by weakened, poorly functioning diaphragm, obstructive airways, during sleep in the event of UAO o On INSPIRATION: lower thorax is

drawn in & the abdomen protrudes

o On EXPIRATION: opposite occurs

DESCRIPTORS OF RESPIRATION

Descriptors of Respiration

Observations

Dyspnea Difficulty & labored breathing w/ SOB

Orthopnea

SOB that begins/ when the px lies down

Paroxysmal Nocturnal Dyspnea

Attacks of severe SOB & coughing that occurs at night, usually awaken the px from sleep

Platypnea Dyspnea in the upright posture Tachypnea Persistent RR > 20/min Bradypnea Rate slower than 12/min Hyperpnea Breathing laboriously & deeply

Respiration Respiration

Acidosis (metabolic)

CNS lesions (pons)

Anxiety

Aspirin poisoning

Oxygen need

Pain

Alkalosis

CNS lesions (cerebrum)

Myasthenia gravis

Narcotic overdose

Obesity (extreme)

ABNORMALITIES IN RATE & RHYTHM OF BREATHING

PERIODIC BREATHING (CHEYNE-STOKES)

Gradual increases and decreases in respiration with periods of apnea

Measure the duration of apnea!

ICP, cerebral injury

Regular periodic w/ intervals of apnea followed by a crescendo/decrescendo sequence of respiration

Children & older adults may breathe in this pattern during sleep

Occurs in patient with brain damage at the cerebral level or w/ drug-caused respiratory compromise

BIOTS RESPIRATION

Rapid, deep respiration (gasps) w/ short pauses between sets


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Breast, and Axilla

More irregular than Kussmaus Spinal meningitis, head injury (medullary)

Irregular respiration varying in depth & interrupted by intervals of apnea but lacking repetitive pattern of Cheyne-Stokes

KUSSMAULS

Tachypnea & hyperpnea

Renal failure, metabolic acidosis, diabetic ketoacidosis

APNEUSTIC

Prolonged inspiratory phase w/ shortened expiratory phase

Lesion in brainstem

SIGHING RESPIRATION

Breathing punctuated by frequent sighs should alert the possibility of hyperventilation syndrome/ emotional stress; occasional sighs: normal

OBSTRUCTIVE BREATHING

Expiration is prolonged because of airway resistance

If RR , px lacks sufficient time for full expiration; chest over expands (air-trapping) & breathing becomes more shallow

PALPATION

Light Palpation

Press in to a depth up to 1cm

Should always precede deep palpation Deep Palpation

Press in about 4cm Areas of the Hand to Use in Palpation

Use To Determine

Palmar surface of fingers & finger pads

Position

Texture

Size

Consistency

Fluid

Crepitus

Form of a mass structure

Ulnar surface of hand & fingers

Vibration

Dorsal surface of hands Temperature

Tenderness (*2B 2016) o If at rib, possible costochondritis o If at intercostal space, ask px to breathe deeply, (+) is an

indication of lung problem

CHEST EXPANSION

Assess for chest expansion 1. Place your thumbs at the level of the 10th ribs (9th ICS

Doc.Bau), with your fingers loosely grasping and parallel to the lateral rib cage

2. Position your hands and slide them medially, enough to raise a loose fold of skin on each side between your thumb and the spine.

3. Ask the patient to inhale deeply. 4. Watch the distance between your thumbs as they move apart

during inspiration 5. Feel for the range and symmetry of the rib cage as it expands

and contracts

PALPATION IN PHYSICAL EXAMINATION

PALPATION

plays a relatively minor role in the examination of the normal chest as the structure of interest (the lung) is covered by the ribs and therefore not palpable.

Specific situations where it may be helpful include:

Accentuating normal chest excursion: Place your hands on the patient's back with thumbs pointed towards the spine. o Remember to first rub your hands together so that they are

not too cold prior to touching the patient o Your hands should lift symmetrically outward when the

patient takes a deep breath o Processes that lead to asymmetric lung expansion, as might

occur when anything fills the pleural space (e.g. air or fluid), may then be detected as the hand on the affected side will move outward to a lesser degree.

o There has to be a lot of pleural disease before this asymmetry can be identified on exam.

1. Thoracic Muscles and Skeleton:

Feel for pulsations, areas of tenderness, bulges, depressions, unusual movements, and positions

Bilateral symmetry

Elasticity o Some elasticity rib cage o Relatively inflexible sternum and xiphoid region o Rigid thoracic spine

Palpating the front fremitus of the patient

Note the quality of the Tactile Fremitus o Palpable vibration of the chest wall that results from speech

or other verbalizations, best felt parasternally at the 2nd intercostal space (ICS), the level of the bifurcation of the bronchi 1. Use either the ball (the bony part of the palm at the base

of the fingers) or the ulnar surface of your hand to optimize the vibratory sensitivity *The bony aspects of the hands are used as they are particularly sensitive for detecting these vibrations

2. Ask the patient to repeat the words ninety-nine or one-one-one. This maneuver is repeated until the entire posterior thorax is covered.

3. If fremitus is faint, ask the patient to speak more loudly or in a deeper voice

4. Palpate and compare symmetrical areas of the lungs 5. Identify and locate any areas of increased, decreased, or

absent fremitus *It disappears below the diaphragm

/ Absent Fremitus excess air

(existing in between the hand & the lungs)

Fremitus Fluid/Mass

(solid transmits better than air)

Emphysema

Pleural effusion

Pleural thickening

Massive pulmonary

Edema

Bronchial obstruction

Lung consolidation

Heavy but non-obstructive secretions

Compressed lungs

Tumor


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Breast, and Axilla

o or absent fremitus = excess air

The said conditions can collect in the pleural space, displacing the lung upwards that the fremitus will be decreased.

o fremitus = presence of fluid/ mass Alter the transmission of air and sound that the fremitus

becomes more pronounced.

Areas to palpate for the front fremitus (Left) & back fremitus (Right)

Diagram for pleural effusion & consolidation

Effusions and infiltrates can perhaps be more easily understood using a sponge to represent the lung. In this model (pictured above): o Infiltrate = blue coloration that has invaded the sponge

itself (left) o Effusion = blue fluid upon which the lung is floating

(right)

Investigating painful areas: If the patient complains of pain at a particular site it is important to carefully palpate around that area. for evidence of o Rib fracture o Subcutaneous air (feels like your pushing on Rice

Krispies or bubble paper), etc.

Other conditions which can be detected during physical examination (palpation/ auscultation): o Crepitus

Crackly or crinkly sensation (both palpated and heard; gentle, bubbly feeling

May indicate the presence of air from a subcutaneous rupture somewhere in the respiratory tract/ lungs, or infection of a gas forming organism (i.e. bacteria)

o Pleural Friction Rub Palpable, coarse, grating vibration usually during

inspiration Caused by inflammation on pleural surfaces (feel of

leather rubbing on leather)

2. Position of the trachea

Palpate the trachea in the supra-sternal notch by either the index finger or both the index and middle fingers to detect its position, central or shifted to one side.

Assess deviation. If deviated, focus ensuing chest exam to upper lobe problem.

Deviation may be secondary to: o Atelectasis o Thyroid enlargement o Significant parenchymal and/or pleural fibrosis o Pleural effusion o Tension pneumothorax o Tumor or nodal enlargements

Palpating the trachea

PERCUSSION

Involves striking one object against another thus producing vibration & subsequent sound waves

In P.E., finger functions as hammer, vibration is produced by impact of finger against tissue

Percussion helps you establish whether the underlying tissues are air-filled, fluid-filled, or solid

Penetrates only 5 7 cm into the chest, however, and will not help you to detect deep-seated lesions

The degree of percussion tone is determined by the density of the medium through which sound waves travel

The more dense the medium, the quieter the percussion tone

CLASSIFICATION OF THE DEGREE OF PERCUSSION TONE

TYPE OF TONE EXAMPLE OF LOCATION

PATHOLOGIC EXAMPLE

Flat Muscle (thigh) Large Pleural effusions (flat tone, decreased fremitus), atelectasis, consolidation

Dull Liver Lobar pneumonia, atelectasis, if you are hitting the tumor itself

Resonant Normal lung Simple chronic bronchitis

Hyperresonance None normally Emphysema, pneumothorax

Tympany Gastric air bubble or puffed out cheek

Large pneumothorax

PERCUSSION NOTES AND THEIR CHARACTERISTICS

TYPE OF TONE

INTENSITY PITCH DURA-TION

QUALITY

Resonant Loud Low Long Hollow

Flat Soft High Short Ext. dull

Dull Medium Med-High Med Thud-like

Tympanic Loud High Med Drum-like

Hyper-resonant

Very loud Very low Longer Booming

HYPERRESONANCE

Abnormal sound in adults

Represents air trapping such as occurs in obstructive lung diseases. e.g. pneumothorax or asthma

Chronic air trapping in the lung (emphysema) and acute air trapping in the pleural space (pneumothorax)

Hyperresonance associated with hyperinflation may indicate: o Emphysema o Pneumothorax o Asthma

DULLNESS OR FLATNESS

Suggests atelectasis, pleural effusion

Suggests air filled tissue displaced by fluid (pleural effusion) or infiltrated with leukocytes and bacteria (pneumonia) and/or atelectasis


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Breast, and Axilla

TECHNIQUES OF PERCUSSION Immediate (direct) percussion

Involves striking the finger or hand directly against the body Mediate (indirect) percussion

The finger of one hand acts as the hammer (plexor) & the finger of the other hand acts as the striking surface

STEPS IN INDIRECT PERCUSSION

1. Place your non-dominant hand on the surface of the body with the fingers slightly spread

2. The distal phalanx of the middle finger placed firmly on the body surface with the other fingers slightly elevated off the surface.

3. Snap the wrist of your other hand

downward, & with the tip of the middle finger sharply tap the IP joint of the finger that is on the body surface.

Essential Points in Percussion

The downward snap of the striking finger originates from the wrist & not the forearm or shoulder.

The tap should be sharp and rapid.

The tip and not the pad of the plexor finger is used (hence SHORT fingernails are required)

LADDER PATTERN FOR PERCUSSION AND AUSCULTATION

Posterior Anterior

Allow hand to swing freely at the wrists, hammering your finger onto the target at the bottom of the down stroke.

A stiff wrist will NOT elicit a correct sound

If you percuss with your right hand stand a bit to the left side of your patient

Ask the patient to cross their hands in front of their chest (grasping the opposite shoulder with each hand): this maneuver pulls the scapulae laterally, away from the percussion field

Work down the alley that exists between the scapula and the vertebral column this helps you avoid percussing over bone

Focus on striking the interphalangeal joint (i.e last joint) of your left middle finger with the tip of the right middle finger.

CUT YOUR NAILS!

The last 2 phalanges of your left middle finger should rest firmly on your patients back

Try to keep the remainder of your fingers from touching the patient (IYKWIM), or rest only the tips on them if this is otherwise too difficult to minimize dampening of the percussion notes

AUSCULTATION

Involves listening for sounds produced by the body

Requires a stethoscope

Most important examination technique for assessing air flow through the tracheobronchial tree

Together with percussion, it also helps the clinician assess the condition of the surrounding lungs and pleural space

Helpful in trying to pin the location of pathologic processes that may be restricted by anatomic boundaries.

Auscultation involves o listening to the sounds generated by breathing o listening for any adventitious (added) sounds o if abnormalities are suspected, listening to the sounds of the

Pxs spoken or whispered voice as they are transmitted through the chest wall

BASIC TYPES OF STETHOSCOPE

Acoustic most commonly used

Magnetic

Electronic

Stereophonic Important Characteristic of a Stethoscope 1. Diaphragm & bell are heavy enough to lie firmly on body

surface 2. Diaphragm cover is rigid 3. Bell is large enough in diameter to span an ICS in an adult &

deep enough so that it will not fill with tissue 4. Rubber or plastic ring around bell edges to ensure secure

contact with body surface 5. Tubing is thick, stiff, & heavy[conducts better] 6. Length: 30.5 - 40 cm [12-18 inches] 7. Earpieces fit snugly & comfortably 8. Angled binaurals point the earpieces toward the nose Involves

striking one object against another thus producing vibration & subsequent sound waves.

TECHNIQUES IN AUSCULTATION

*from Bates Listen to the breath sounds with the diaphragm of a stethoscope

after instructing the patient to breathe deeply

Use the pattern for percussion, moving from one side to the other and comparing symmetric areas of the lungs

If you hear or suspect abnormal sounds, auscultate adjacent areas so that you can fully describe the extent of any abnormality

Listen to at least one full breath in each location. Note the intensity of the breath sounds

Breath sounds are usually louder in the lower posterior lung fields and may also vary from area to area

If the breath sounds seem faint, ask the patient to breathe more deeply; you may then hear them easily

1. Put on your stethoscope so that the earpieces are directed away from you (Dapat hindi tumama sa mata) Adjust the head of the scope so that the diaphragm is

engaged


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Breast, and Axilla

If youre not sure, scratch the diaphragm lightly, which should produce a noise

If not, twist the head and try again (aray!). Gently rub the head on your shirt so that its not too cold prior to placingit on the patients skin (ohoho!)

2. The upper aspect of the posterior field (top of the patients back) are examined first

Listen over to one spot then move the stethoscope to the same position on the opposite side and repeat. The otherlung will serve as a comparison for the other (similar to what is done in percussion)

The entire posterior chest can be covered by listening in roughly 4 places on each side

When you hear something abnormal, youll need to listen in more places (particularly regions adjacent/near the region with abnormal sound)

3. The lingual and right middle lobes can be examined while you are standing behind the patient

4. Then, move around to the front and listen to the anterior fields in the same fashion. This is generally done while the patient is still sitting upright.

Asking female patients to lie down this will allow their breasts to fall away laterally, which may make this part of the examination easier.

Additional Notes 1. Ask the patient to take slow, deep breaths through their mouths

while you are performing your exam.

This forces the patient to move greater volumes of air with each breath, increasing the duration, intensity, and detectability of any abnormal breath sounds that might be present.

2. Have the patient cough a few times prior to auscultation.

o This clears airway secretions and opens small atelectatic areas at the lung bases

o If the patient cannot sit up, auscultation can be performed while the patient is lying on their side.

o Get help if the patient is unable to move on their own o In cases where even this cannot be accomplished, a minimal

examination can be performed by listening laterally/posteriorly as the patient remains supine

3. Requesting that the patient exhale forcibly will occasionally

help accentuate abnormal breath sounds (e.g. wheezing) that might not be heard at normal flow rates.

BREATH SOUNDS

Made by the flow of air through the respiratory tree; characterized by pitch, intensity, duration of inspiratory & expiratory phases

Classified as: o Vesicular o Bronchovesicular o Bronchial (tubular)

A healthy individual breathing through their mouth at normal tidal volumes produces vesicular breath sounds o Inspiratory component seems to arise in the lung periphery o Expiratory component arises in the more proximal larger

airways o Detecting differences in pitch and intensity is often easier

during expiration

Turbulent air flow in the central airways produces the tracheal and bronchial breath sounds

If bronchovesicular or bronchial breath sounds are heard in locations distant from those listed, suspect that air-filled lung has been replaced by fluid-filled or solid lung tissue

ADVENTITIOUS (ADDED) SOUNDS

Detection of adventitious sounds crackles (sometimes called rales), wheezes, and rhonchi is an important part of your examination, often leading to diagnosis of cardiac and pulmonary conditions

1. Crackles

Abnormal respiratory sound heard more often during inspiration; characterized by discrete discontinuous sounds, each lasting just few milliseconds

Caused by disruptive passage of air through the small airways in the respiratory tree

May be fine, high-pitched (sibilant) or coarse, low pitched (sonorous)

Characteristics: o loudness, pitch and duration (summarized as fine or coarse) o number (few to many) o timing in the respiratory cycle o characteristic from breath to breath

Crackles may be heard in some normal people at the anterior lung bases after maximal expiration

Crackles in dependent portions of the lungs may occur after prolonged recumbency

Persistence of their pattern from breath to breath

Fine late inspiratory crackles that persist from breath to breath suggest abnormal lung tissue

Any change after a cough or change in the patients position

Clearing of crackles, wheezes, or ronchi after coughing or position change suggests inspissated secretions, seen in bronchitis or atelectasis.

Crackles may result from:

A series of tiny explosions when small airways, deflated during expiration, pop open during inspiration

From air bubbles flowing through secretions or lightly closed airways during respiration

2. Wheeze

A continuous, high pitched musical sound, almost a whistle, heard during inspiration or expiration

Caused by a relatively high velocity air flow through a narrowed airway


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Breast, and Axilla

3. Rhonchi

Deeper, more rumbling, more pronounced during expiration, more likely to be prolonged and continuous and less discrete than crackles

Passage of air through an airway obstructed by thick secretions, muscular spasm, new growth, or external pressure

In general: rhonchi tend to disappear after coughing, whereas crackles do not

ADVENTITIOUS SOUNDS

DESCRIPTION CAUSES

DISCONTINUOUS intermittent; non-musical

Fine crackles (Rales crepitants)

Soft, high-pitched, very brief (short duration

Pneumonia, fibrosis, CHF

Coarse crackles (Rales bulleux)

Louder, low-pitched, not so brief (long duration

Bronchitis, Bronchiectasis

CONTINUOUS longer than crackles; musical

Wheezes (Rales sibilants)

High-pitched, hissing or shrill quality

Asthma, COPD, bronchitis

Rhoncus (Rales ronflants)

Low-pitched, snoring quality

Secretions in large airways

4. Friction Rub

Occurs outside the respiratory tree dry, crackly, grating, low-pitched sound heard in both expiration and inspiration with machine-like quality

5. Stridor

Loud, harsh musical breathing sound that unlike the wheezes of bronchial origin is chiefly inspiratory

Suggests partial obstruction of the larynx or trachea

6. Mediastinal Crunch (Hammans sign) Found with mediastinal emphysema (pneumomediastinum)

Great variety of noise - loud crackles, clicking and gurgling sounds

Synchronous with the heartbeat and not with respiration

Easiest to hear when the Px leans to the left (left lateral position)

7. Pleural Effusion

Auscultation over a pleural effusion will produce a very muffled sound. If, however, you listen carefully to the region on top of the effusion, you may hear sounds suggestive of consolidation, originating from lung which is compressed by the fluid pushing up from below

Asymmetric effusions are probably easier to detect as they will produce different findings on examination of either side of the chest.

8. Severe, Stable, Emphysema

Auscultation of patients with severe, stable emphysema will produce very little sound

Patients suffer from significant lung destruction and air trapping, resulting in their breathing at small tidal volumes that generate almost no noise.

Wheezing occurs when there is a superimposed acute inflammatory process

TRANSMITTED VOICE SOUNDS (VOCAL RESONANCE)

If you hear abnormally located broncho-vesicular or bronchial breath sounds (as in pneumonia), continue on to assess transmitted voice sounds

With a stethoscope, listen in symmetric areas over the chest wall as you assess for bronchophony, egophony, and whispered petriloquy

Increased transmission of voice sounds air-filled lung has become airless.

1. BRONCHOPHONY

Ask patient to say ninety-nine. Normally, the sounds transmitted through chest wall are

muffled and indistinct

Greater clarity & increased loudness of spoken words o suggests that air-filled lung has become airless

2. EGOPHONY

Ask the patient to say ee. You will normally hear a muffled long E sound When ee is heard as ay, an E-to-A change (egophony)

is present, as in lobar consolidation from pneumonia

Intensity of spoken voice is increased

Quality sounds nasal (es become stuffy broad as)

3. WHISPERED PETRILOQUY

Ask the patient to whisper ninety-nine or one-two-three.

The whispered voice is normally heard faintly and indistinctly, if at all.

Louder, clearer whispered sounds are called whispered pectoriloquy.

SUMMARY OF EXAMINATION: CHEST AND LUNGS

1. Inspect the chest , front & back, noting thoracic landmarks

size & shape (AP diameter compared with transverse)

symmetry

color

superficial venous patterns

prominence of ribs 2. Evaluate respirations for the following:

rate

rhythm or pattern 3. Inspect chest movement with breathing for the following:

symmetry

bulging

use of accessory muscles 4. Note any audible sounds with respirations

e.g. stridor ,wheezes, etc. 5. Palpate the chest for the following:

symmetry

thoracic expansion

pulsations

sensations such as crepitus, grating vibrations

tactile fremitus 6. Perform direct or indirect percussion on the chest,

comparing sides for:

intensity

pitch

duration

quality 7. Auscultate the chest comparing sides for the following:

intensity, pitch, duration and quality of expected breath sounds

unexpected breath sounds (crackles, rhonchi, wheezes, friction rubs)

vocal resonance

PHYSICAL EXAMINATION OF BREAST AND AXILLAE* FEMALE BREAST

* Lifted from Bates

Paired mammary gland that lies against the anterior thoracic wall


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Breast, and Axilla

Extends: o from the clavicle and the 2nd rib down to the 6th rib, and o from the sternal margin across to the midaxillary line

Its surface area is generally rectangular rather than round

Overlies the pectoralis major and, at its inferior margin, the serratus anterior

Muscles forming the floor of the breast: o pectoralis major/minor o serratus anterior o latissimus dorsi o subscapularis o external oblique o rectus abdominis

Blood supply: internal mammary/lateral thoracic

Composed of secretory tubuloalveolar glands and ducts that forms 15 to 20 lobes radiating around the nipple

Within each lobe are many smaller lobules that drain into milk-producing ducts and sinuses that open onto the surface of the areola, or nipple

Fibrous connective tissue o Provides structural support in the form of fibrous bands or

suspensory ligaments connected to both the skin and the underlying fascia

Adipose tissue/fat o Surrounds the breast, predominantly in the superficial and

peripheral area o Proportions of these components vary with:

Age General state of nutrition Pregnancy Exogenous hormone use

Supernumerary nipples o Extra nipples located along the milk line, and only a small

nipple and areola are usually present, often mistaken for a common mole

o there may be underlying glandular tissue o No pathologic significance

Five Segments of the Breast: o Based on horizontal and vertical lines crossing the nipple:

Upper Outer Quadrant greatest amount of glandular tissue

Lower Outer Quadrant Upper Inner Quadrant Lower Inner Quadrant Tail of Spence- extends toward the anterior axillary fold

Nipple and areola o Both are well supplied with smooth muscle that contracts to

express milk from the ductal system during breast-feeding o Rich sensory innervations (esp. in the nipple) triggers milk

letdown following neurohormonal stimulation from infant sucking

o Tactile stimulation of the area, including the breast examination, makes the nipple smaller, firmer, and more erect, while the areola puckers and wrinkles (these normal smooth muscle reflexes should not be mistaken for signs of breast disease)

MALE BREAST

Consists of a small nipple and areola

Overlie a thin disc of undeveloped breast tissue

LYMPHATICS

LYMPH NODE LOCATION DRAINAGE

Pectoral nodes (Anterior)

Lower border of the pectoralis major inside the anterior axillary fold

Anterior chest wall and much of the breast

Subscapular nodes (Posterior)

Lateral border of the scapula, palpated deep in the posterior axillary fold

Posterior chest wall and a portion of the arm

Lateral nodes Upper humerus Most of the arm

Central axillary nodes

Midway between the anterior and posterior axillary folds

Channels from central axillary nodes

Infraclavicular nodes

Below the clavicle *not strictly axillary nodes, located outside the axilla

Channels from the central axillary nodes

Supraclavicular nodes

Above the clavicle Channels from central axillary nodes

*Snell, 9th ed

Central nodes are palpable most frequently

Lymph drains from the central axillary nodes to the infraclavicular and supraclavicular nodes

Not all lymphatics of the breast drain into the axilla

Malignant cells from a breast CA may spread directly to the infraclavicular nodes into deep channels within the chest

HEALTH HISTORY

Common or concerning symptoms: o Breast lump or mass o Breast pain or discomfort o Nipple discharge

BREAST LUMP OR MASS

Lumps may be physiologic or pathologic, ranging from cysts and fibroadenomas to breast CA

Temporal sequence length of time since lump first noted

Symptoms tenderness

pain

dimpling

change in color

Changes in lump size

character

relationship to menses

Associated symptoms nipple discharge

tender lymph nodes

Medications


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Breast, and Axilla

BREAST PAIN OR DISCOMFORT

Temporal sequence length of time since lump first noted

sudden or gradual

duration

Relationship to Menses

Character pulling

throbbing

burning

stabbing

Associated symptoms nipple discharge

Lumps/Mass

Contributory factors skin irritation

recent injury to breast

Efforts to Treat Medications

NIPPLE DISCHARGE

Does the discharge appear only after compression of the nipple, or is it spontaneous? o If it appears only after squeezing the nipple, it is considered

physiologic Physiologic hypersecretion: pregnancy, lactation, chest

wall stimulation, sleep, and stress o If spontaneous:

what is the color, consistency, and quantity? Is the color milky, brown or greenish, or bloody? Ask if the discharge is unilateral or bilateral

Galactorrhea is the inappropriate discharge of milk-containg fluid. If it occurs 6 or more months after child birth or cessation of breast-feeding it is ABNORMAL.

A nonmilky unilateral discharge suggests local breast disease

PAST MEDICAL HISTORY

Menstrual history menarche/menopause

Pregnancy

Lactation

Surgeries: biopsies, aspirations, implants

Previous breast disease: cancer, fibroadenomas, fibrocystic disease

Use of hormonal medications

FAMILY HISTORY Positive Family History - First-degree relatives, namely a

mother or sister with breast cancer Having first-degree relatives with breast cancer who are

premenopausal with bilateral dis-ease confers the highest risk.

MODIFIABLE VS. NON-MODIFIABLE RISK FACTORS

There are modifiable and non-modifiable factors that increase the risk of having breast cancer

Non-modifiable: age, family history, age at first full-term pregnancy, early menarche, late menopause, breast density etc.

Modifiable: postmenopausal obesity, use of HRT, alcohol use, physical inactivity etc.

VISIBLE SIGNS OF BREAST CANCER

Retraction Signs

As breast cancer advances, it causes fibrosis (scar tissue).

Shortening of this fibrotic tissue produces retraction signs, including: o Dimpling o changes in contour o retraction or deviation of

the nipple.

Other causes of retraction include: o fat necrosis o mammary duct ectasia.

Skin Dimpling

Look for this sign with the patients arm at rest, during special positioning, and on moving or compressing the breast

Edema of the Skin

Edema of the skin is produced by lymphatic blockade.

Appears as thickened skin with enlarged poresthe so-called peau dorange (orange peel) sign.

Often seen first in the lower portion of the breast or areola.

Abnormal Contours

Look for any variation in the normal convexity of each breast, and compare one side with the other.

Special positioning may again be useful. Shown here is marked flattening of the lower outer quadrant of the left breast.

Nipple Retraction and Deviation

A retracted nipple is flattened or pulled inward.

It may also be broadened, and feels thickened.

When involvement is radially asymmetric, the nipple may deviate, e.g. point in a different direction from its normal counterpart, typically toward the underlying cancer.

Pagets Disease of the Nipple

This is an uncommon form of breast cancer that usually starts as a scaly, eczema like lesion.

The skin may also weep, crust, or erode.

A breast mass may be present.

Suspect Pagets disease in any persisting dermatitis of the nipple and areola

EXAMINATION OF THE BREAST INSPECTION

MALE BREAST Brief but just as important If breast appears enlarged, distinguish between the soft fatty

enlargement of obesity and the firm glandular enlargement of gynecomastia

Inspect nipple and areola Inspect skin of each axilla

Nodules Swelling Ulceration

Rash Infection Unusual pigmentation

FEMALE BREAST Inspect breasts while patient is at sitting position and disrobed to

the waist Inspect for the following: o Size, shape, location


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Breast, and Axilla

o Skin changes o Symmetry o Contour o Retraction in 4 views: arms at sides, arms over head, arms

pressed against hips, and leaning forward

VIEW NOTE FINDINGS

ARMS AT SIDES

Appearance of skin including: Color Thickening Unusually prominent pores Size and

symmetry Contour (masses,

dimpling, or flattening)

Nipple charac. (size, shape, direction, rashes or

ulceration, discharge)

Redness from infection or inflammation carcinoma

Thickened and prominent pores suggest breast cancer (Peau d Orange)

Flattening of normally convex breasts and asymmetry in which nipples point suggest cancer

Recent or fixed flattening of nipple suggest retraction

ARMS OVER HEAD

A mass in the pectoralis fascia leads to contour changes

Px to raise her arms over her head

View contour changes

Prominent findings in this position:

Dimpling or retraction that suggest cancer

ARMS PRESSED AGAINST HIPS

This position allows tension of pectoralis major muscle Examiner moves the mass to determine fixation to the underlying fascia

ccasionally associated with benign lesions (i.e. posttraumatic fat necrosis, or mammary duct ectasia) More prominent in this position: lumps that suggest cancer

LEANING FORWARD

If the Px have large and pendulous breasts

Retraction and masses become more evident

o Retraction of nipple and areola suggest underlying cancer

o More prominent in this position: 1. breast assymetry

PALPATION

PATIENT PREPARATION 1. Have the patient lie supine on the exam table. Palpation is best performed when the breast tissue is flattened.Therefore, the patient should be supine.

2. Ask the patient to remove the gown from one breast.

PALPATION OF THE BREAST

Use the pads of index, middle, ring fingers during palpation. If open sores or discharge are visible, wear gloves.

Press the breast tissue against the chest wall in small circular motions. Use very light pressure to assess superficial layer, moderate pressure for middle layer and firm pressure for deep layers.

TECHNIQUES IN PALPATING THE BREASTS

Vertical Strip Pattern Currently the best validated technique for detecting breast masses.

Concentric Circles 2nd most used technique

Wedge Least commonly used

Palpate systematically all 4 quadrants including the tail of Spence; feel for the lumps and nodules. a. To examine the lateral portion of the breast (using the vertical

strip pattern):

Ask the patient to roll onto the opposite hip, placing her hand on her forehead but keeping shoulders pressed against the bed. This flattens the lateral breast tissue.

Begin palpation in the axilla, moving in a straight line down to the bra line, then move the fingers medially and palpate in a vertical strip up the chest to the clavicle.

Continue in vertical overlapping strips until you reach the nipple, and then reposition the patient to flatten the medial portion of the breast.

b. To examine the medial portion of the breast (using the vertical

strip pattern)

Ask the patient to lie with her shoulders flat against the bed, placing her hand at her neck and lifting her elbow until it is even with her shoulder. This position allows the medial part of the breast to be examined better.

Palpate in a straight line, down from the nipple to the bra line then back to the clavicle, continuing in vertical overlapping strips to the mid-sternum.


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Breast, and Axilla

PALPATION OF THE NIPPLES

The nipples should be palpated both in males and females. 1. Press it gently between the thumb and index finger. 2. Make note of any discharge. If discharge appears, note the

color and characteristics. o Milky o Multicoloured sticky o Purulent o Watery o Serous o Serosanguinous

3. Have the patient replace the gown and repeat on the other side.

NIPPLE AREOLA

Homogenous color and matches that of the areola Mostly everted but one or both nipples may be inverted Recent unilateral inversion or retraction of a previously everted nipple may be a sign of malignancy Retraction-flattening, withdrawal, or inversion of nipple: indicates pulling by inflammatory or malignant tissue

Round or oval Bilaterally equal or nearly equal Color pink to black May have hair

SUMMARY OF BREAST CANCER RISK FACTORS

FACTOR RELATIVE RISK

FAMILY HISTORY

First degree relative with breast cancer (mother or daughter)

1.2 3.0

Premenopausal 3.1

Premenopausal and bilateral 8.5 9.0

Postmenopausal 1.5

Postmenopausal and bilateral 4.0 5.4

MENSTRUAL HISTORY

Age at menarche 55 1.5 2.0

PREGNANCY

First live birth age 25-29 1.5

First live birth after 30 1.9

First live birth after 35 2.0 3.0

Nulliparous 3.0

BREAST CONDITIONS AND DISEASE

Nonproliferative disease 1.0

Proliferative disease 1.9

Proliferative with atypical hyperplasia 4.4

Lobular carcinoma in situ 6.9 12.0

EXAMINATION OF THE AXILLA

Although the axillae may be examined with the patient lying down, a sitting position is preferable.

INSPECTION Inspect the skin of each axilla, noting evidence of:

o Rash o Infection o Unusual pigmentation

PALPATION 1. To examine the left axilla, ask the patient to relax with the left arm

down. Help by supporting the left wrist or hand with your left hand.

2. Cup together the fingers of your right hand and reach as high as you can toward the apex of the axilla.

3. Warn the patient that this may feel uncomfortable. Your fingers should lie directly behind the pectoral muscles, pointing toward the midclavicle.

4. Now press your fingers in toward the chest wall and slide them downward, trying to feel the central nodes against the chest wall. Of the axillary nodes, these are the most often palpable. One or more soft, small (

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

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Breast, and Axilla

COMMON BREAST MASSES

FIBROADENOMA CYSTS CANCER

Usual Age 15-25, usually puberty and young adulthood, but up to age 55

30-50, regress after menopause except with estrogen therapy

30-90, most common over age 50

Number Usually single, may be multiple Single or multiple Usually single, although may coexist with other nodules

Shape Round, disc-like, lobular Round Irregular or stellate

Consistency May be soft, usually firm Soft to firm, usually elastic Firm or hard

Delimitation Well delineated Well delineated Not clearly delineated from surrounding tissues

Mobility Very mobile Mobile May be fixed to skin or underlying tissues

Tenderness Usually non-tender Often tender Usually non-tender

Retractions Absent Absent May be present

med 1.4 pe of the chest, lungs, breast, and axilla.pdf

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