1/8/08
1/11/08
Phys Dx II – exam 1
Respiratory System Exam
Respiratory System Exam
-Part of a Complete Physical Exam
-Symptoms/Complaints
-Risk Factors
Respiratory System Symptoms
■ Cough
■ Productive vs Non-productive (sputum production)
■ Hemoptysis (coughing up blood)
■ Dyspnea (SOB)
■ Wheezing
■ Cyanosis
Relevant History
■ Employment (exposure to irritants)
■ Home environment (allergens)
■ Flame-retardants (esp. w/ infants)
■ Tobacco (pack yrs= #yrs x #packs/day)
■ Exposure to respiratory infections
■ Nutritional status
■ Obese are more prone to infections
■ Travel Exposures
Respiratory System Risk Factors
■ Gender: > males (partly due to work environ.), gender difference decreases w/ aging (due to pulmonary edema)
■ Age: increases with advancing age
■ Family Hx: Asthma, CF, TB, other contagious ds, neurofibromatosis
■ Smoking
■ Sedentary life-style / immobilization (couch-potatoes have a greater risk for infection)
■ Occupational exposure
■ Extreme obesity
■ Difficulty swallowing
■ Weakened chest muscles
■ Hx. of frequent respiratory infections
■ Severe cardiovascular disease
Coughing
■ Onset
■ Palliative/Provocative
■ Quality (Nature of cough)
■ Severity
■ Pattern
■ Associated Symptoms
■ Treatment (type, effect)
Appearance of Sputum (table 13-2)
■ Mucoid (asthma, TB, emphysema)
■ Mucopurulent (asthma, TB, emphysema)
■ Yellow-green/ purulent (bronchiectasis)
■ Rust-colored/ Purulent (pneumococcal pneumonia)
Hemoptysis (table 13-3)
■ Onset (sudden, recurrent)
■ Descriptor (blood tinged, clots)
■ History of smoking, infections, meds, surgery, (females - oral contraceptives)
■ Associated symptoms
■ Hemoptysis vs Hematemesis
Hemoptysis = coughing blood
-possible history of cardiopulmonary disease
-pink and frothy sputum; mixed with pus
-dyspnea
Hematemesis = vomiting blood
-possible history of GI disease
-not frothy sputum; mixed with food
-dark red, brown, or “coffee grounds”
-nausea
1/14/07
Dyspnea (SOB) (table 13-8)
■ Onset (when, mode, progression)
■ Palliative
■ Provocative (exertional, positional)
■ Pattern
■ Associated symptoms
■ Associated conditions
Common Conditions Associated with Dyspnea (table 13-8)
Asthma – episodic attacks, wheezing, chest pain, productive cough (thick, mucoid, hard to expectorate the sputum)
Pneumonia – insidious onset of dyspnea, cough
Pulmonary edema – abrupt; tachypnea, cough, orthopnea, nocturnal dyspnea (positional dyspnea)
Pulmonary fibrosis – progressive, tachypnea, dry cough
Pneumothorax – moderate to severe dyspnea, sudden pleuritic chest pain
-spontaneous pneumothorax occur in healthy, thin, young males (bleb that ruptures)
Emphysema – insidious onset, severe dyspnea; cough
Chronic bronchitis – chronic productive cough
Obesity – exertional dyspnea
Dyspnea of Rapid Onset (within 24-hour period)
■ Pneumonia
■ Pneumothorax
■ Pulmonary Constriction
■ Peanut (or inhaled foreign object)
■ Pulmonary Embolus
■ Pericardial Tamponade
Wheezing & Noisy Breathing
■ Wheezing: Abnormally high-pitched suggest bronchiospasm or compression
■ Rhonchi: Harsher sounds suggesting secretions in larger airways.
■ Stridor: Harsh wheeze entirely or predominately in inspiration which suggest partial obstruction of larynx or trachea
Causes of Wheezing or Noisy Breathing
■ Infections (can lead to edema &/or mucus production)
■ Irritants & Allergens
■ Compression of the Airway (ie tumors, aneurysm)
■ Congenital Malformations/Abnormality (ie atresia)
■ Acquired Abnormalities at any level of airway (tumors, stenosis)
■ Neurogenic Disorders (something that can affect the diaphragm, ie phrenic nerve pblm)
**Positional Dyspnea (page 369) – table 13-4
■ Paroxysmal nocturnal dyspnea (PND)
■ Sudden onset occurring while sleeping, relieved by assuming upright position (CHF)
■ Orthopnea – lying flat requires multiple pillows (CHF, mitral valvular disease)
■ Trepopnea – more comfortable on side (in later stage CHF)
■ Platypnea – problems sitting up, patient breaths easier in recumbent position (neuro ds., hypovolemia, cirrhosis)
Cyanosis (Bluish Discoloration)
■ Central – cardiorespiratory pblm
■ Dec. O2 in lungs
■ Severe C/R ds.
■ Lips, oral mucosa, nail beds
■ Gets worse with warming of body
Chest Pain
■ OPPQRST & Assoc Sx, Treatments
■ Differential:
■ Cardiovascular
■ Respiratory (Pleural involvement)
■ Gastrointestional (esophageal pblms)
■ Chest Wall Syndrome
■ Psychogenic
-likely not a heart attack, unless pt. is diaphoretic
Chest pain – Tracheobronchitis
-Inflammation of trachea & large bronchi associated with upper sternal and/or parasternal pain
Quality: burning
Associated symptom: coughing
Provocative: unfortunately coughing
Palliative: lying on the involved side may provide relief
Chest Pain – Pleural
-Inflammation of the parietal pleura (pleurisy, pneumonia, neoplasm, or pulmonary infarction)
-Constant pain of the chest wall overlying area of involvement
Quality: sharp and stabbing, often severe
Provocative: breathing, coughing, movements of the trunk
Apnea - The absence of spontaneous breathing
■ Deglutition – apnea during swallowing is a normal response
■ Primary – if a person has fallen or got hit in the chest (wind knocked out of you) – not an abnormality
■ Reflex – not an abnormality (ie strong odors, like sulfur)
■ Secondary – IS an abnormality (damage to respiratory centers, MI, stroke, etc) – pt. needs resuscitation
■ Selective – when person selectively decides to hold breath (ie diving into water)
■ Sleep – biggest concern with patients (even 10 seconds can have deleterious effects)
■ Multiple causes: often cardiovascular pblm, obesity (fat in airways), or incr intracranial pressure
■ (but mostly idiopathic)
■ If obese, losing weight or exercise often will get rid of sleep apnea
1/15/07
Examination Sequence
■ Peripheral Assessment
■ Inspection of Chest & Thorax
■ Palpation
■ Percussion
■ Auscultation
[pic]
*Sweet, fruity – diabetic ketoacidosis; starvation ketosis
*Ammonia-like – uremia
*Foul, feculent – intestinal diverticulum
*Cinnamon – pulmonary TB
Clover – hepatic failure
Clubbing of Nails – chronic hypoxia
-Intrathoracic tumors
-congenital heart malformations
-mixed venous-to-arterial shunts
-Acquired cardiopulmonary disease
-chronic pulmonary disease
-chronic hepatic fibrosis
Inspection of the Chest/Thorax
■ Note Shape & Movement of Chest
■ Observe Effort of Breathing
■ Rate, Rhythm, Depth, Audible sounds
■ Note Any Skin Lesions
■ Slope of Ribs and Motion
■ Symmetrical with no retraction or lag
(retraction=sucking in; lag=decr motion)
Ds. of Chest Expansion/Lag
■ Chronic fibrotic disease (lung or pleura)
■ Pleural effusion
■ Pneumothorax
■ Lobar pneumonia
■ Pleural Pain (splinting)
■ Unilateral bronchial obstruction
-barrel-shaped chest is normal in infants
-Pectus Excavatum (funnel-shaped chest) – depression of lower portion of sternum
-poor posture & pot belly
-may lead to compression of great vessels & heart murmurs
-Marfan’s is classically associated with pectus excavatum (& Rickets in third-world countries)
-Pectus Carinatum (pigeon chest) – sternum is displaced anteriorly
-costocartilage adjacent to the sternum are depressed
-severe scoliosis can lead to this
-used to be a classic distortion in children with asthma
[pic]
Ds. Of Chest expansion/Lab (B/L)
-chronic fibrotic disease (lung/pleura) – B/L
-obesity
-COPD
-Ascites – organomegaly
-Diaphragmatic disease
Respiration - rate, rhythm, depth
Normal adult resting respiration: 10-20 breaths/min, regular rhythm, relaxed with no use of accessory muscles
( 4:1 ratio with heart rate
Respiration Terms
Bradypnea: 20 bpm & shallow (rib fracture)
-pleural involvement (pleurisy)
Hyperpnea: deeper & more rapid
-stress, exercise, anxiety
-Kussmaul (rapid, deep, labored)
-metabolic acidosis (diabetes, kidney failure)
Apnea: temporary halt in breathing
Influences Rate & Depth of Breathing
Increases with:
Acidosis, CNS lesions-Pons, anxiety, pain, hypoxemia, aspirin poisoning
Decreases with:
Alkalosis, CNS-cerebrum, severe obesity, myasthenia gravis, narcotic overdose
[pic]
Palpation of Chest/Thorax
-tender areas
-evaluate skin lesions, abnormal bulges or depressions
-determine tracheal position (place fingers on either side of tracheal, but medial to the SCM)
-it is not uncommon for there to be slightly less left spacing than right (mediastinum)
-also, it should move freely
-assess chest expansion (rib excursion)
-tactile (vocal) fremitus
-estimate level of the diaphragm
Tender regions
-palpate for tender areas on the chest wall or thorax using ulnar surface of hand, MCP joints or distal pad of your fingers. -skin changes or lesions should be further delineated and defined
Tracheal Deviation
■ *Pulled: Open pneumothorax, Fibrosis, Atelectasis (upper lobe), infiltrative tumor, pneumothorax
■ *Pushed: Tension pneumothorax, Tumor, Thyroid or lymph node enlargement (Hodgkin’s), Pleural Effusion
■ Pushed posterior: Mediastinal tumors, goiter
■ Pushed anterior: Mediastinitis
1/18/07
Tactile (Vocal) Fremitus
■ Palpable or auditory vibration of the chest wall resulting from speech or other verbalizations. “99”, “1,1,1”
■ Ulnar surface of the hand, MCP, Pads
■ Simultaneous or Alternating side to side, down and across
-most cancers are small masses and will not alter our exam findings
*Table 13-5. Changes in Tactile Fremitus (sound transmission)
-anything that causes the parenchyma to become more solid, transmits more sound (ie lobar pneumonia)
Increased tactile fremitus: pneumonia, atelectasis that is close to the main stem bronchus (rare)
Decreased tactile fremitus:
U/L: pneumothorax, pleural effusion, bronchial obstruction, atelectasis (incomplete expansion of lung tissue)
B/L: chronic obstructive lung disease, chest wall thickening (muscle, fat)
Estimate Level of Diaphragm
■ Approximation through Tactile Fremitus
■ Abnormally high diaphragm:
■ Pleural Effusion
■ Paralysis of Diaphragm
■ Organomegaly
■ Atelectasis (Lower lobe) – absorbs the sound rather than transmit it
■ Pregnancy
-start at inferior level of scapula and have patient say “99” – diaphragm should be around the T10 level
Percussion
■ Creates sound waves that travel inward 5-7 cm (assesses a superficial or peripheral lesion)
■ Percussion note (intensity, pitch, duration)
■ Diaphragmatic excursion: change between inspiration and expiration
Percussion Note (page 379)
[pic]
Diaphragmatic Excursion
■ Level between the Resonance/Dullness on full inspiration vs expiration. 3-6 cm (4-5 cm according to Swartz)
■ Depends on size and level of activity of patient (can be up to 8cm in athletes) – not concerned with incr
■ Decrease B/L: *Emphysema, Thickened chest wall, Elevated diaphragm, Ascites, B/L Organomegaly, B/L Collapse
■ Decrease U/L: Same conditions as Lag – U/L pleural effusion, pneumothorax, bronchial obstruction, organomegaly, consolidation (lower lobe)
■ Absent: Inflammation of diaphragm or visceral below, Phrenic nerve palsy
-sucking in stomach, sticking out chest, and throwing back your shoulders all lead to an inefficient way of breathing (using more of the accessory muscles)
Auscultation
■ Breath Sounds (type, intensity)
■ Adventitious Sounds
■ Vocal Resonance
■ Bronchophony
■ Egophony
■ Whispered Pectoriloquy
Tracheal – very loud harsh sound (consistent with the extrathoracic trachea); high pitch, Inspiration:Expiration ratio = 1:1
Bronchial – loud, and high pitch; I:E = 1:3
Bronchovesicular – moderate intensity & pitch; I:E = 1:1; sounds like rustling
Vesicular – quiet, soft intensity, low pitch; vast majority of lung field; I:E = 3:1; gentle rustling
-quieter sounds = more tissue that the sound must travel through
-the same conditions that alter tactile fremitus can also alter the breath sounds
-ie pneumonia (consolidation) increases the harshness
Breath Sound Intensity
■ Increase:
■ Pneumonia w/ Consolidation (classic)
■ Atelectasis in the Upper Lobe or adjacent
to the main stem Bronchi
■ ?Diffuse Fibrosis (depends on extent of fibrosis)
Adventitious Sounds (Added)
■ Superimposed on the Breath Sounds (extra sounds)
■ Crackles (Rales)
■ Wheezes & Rhonchi (rhonchi are harsher sounds assoc with more fluid)
■ Pleural Friction Rub (when pleural involvement; ie pleural effusion and pneumothorax)
■ Stridor (inspiratory harsh sound assoc with partial tracheal or laryngeal obstruction)
Table 13-7. Adventitious Sounds
Crackle – excess airway secretions (ie Bronchitis, infections, pulmonary edema, atelectasis, fibrosis, CHF)
Wheeze – rapid airflow through obstructed airway (ie Asthma, pulmonary edema, bronchitis, CHF)
Rhonchus – transient airway plugging (ie Bronchitis)
Pleural Rub – Inflammation of the pleura (ie pneumonia, pulmonary infarction, pleurisy, small pneumothorax, or small pleural effusion)
1/22/08
-pleural effusion is the only condition with a transition area b/n decreased and increased tactile fremitus (?)
-pneumothorax shifts the trachea to the opposite side
Vocal Resonance
■ Transmitted voice sounds “99”, “1,1,1”
■ When abnormal breath sound is heard may help to further delineate the area.
■ Enhance: consolidation (lobar pneumonia), airless lung
■ Decrease: blockage of respiratory tree, or over-inflated lungs, thickened chest wall
■ When an area of abnormality is noted during auscultation, especially bronchial breath sounds any of these tests can be used to localize the area of involvement
■ Bronchophony – spoken words are louder, clearer, more audible
■ Egophony – “ee” is heard as “ay”
■ Whispered Pectoriloquy – whispered words are louder, clearer
-in your office, bronchophony is the only one that needs to be tested for
Table 13-9. Differentiation of Common Pulmonary Conditions
Asthma – tachypnea, tachycardia, dyspnea, use of accessory muscles, often normal palpation & percussion
Emphysema – stable vital signs, wasting, decr tactile fremitus, incr resonance, decr lung sounds
Chronic bronchitis – tachycardia, often normal palpation & percussion, rhonchi & early crackles
Pneumonia – tachycardia/pnea, incr tactile fremitus, dull percussion, late crackles
Pulmonary Embolism – tachycardia/pnea, usually normal exam
Pulmonary edema – tachycardia/pnea, wheezes
Pneumothorax – tachycardia/pnea, inspection may be normal, absent fremitus, hyperresonant percussion
-a small pneumothorax (contained) will self-resolve, even though there is a little pain
Pleural effusion – tachycardia/pnea, decr fremitus, dull percussion, absent breath sounds
Atelectasis – tachypnea, decr fremitus, dull percussion, absent breath sounds
Acute resp distress syndrome – tachycardia/pnea, use of accessory muscles, cyanosis
[pic]
[pic]
*know conditions that can have BLOOD (table 7-3)
– bacterial pneumonia, chronic bronchitis, bronchiectasis, TB, lung abscess, cancer, pulmonary emboli
TB – cough dry or sputum that is mucoid or purulent; may be bloody
Lung abscess – bloody, foul-smelling sputum
GI reflux – cough
Pulmonary emboli – after surgery or person with problem with venous stasis and sits a lot; may cough up blood
-----------
Breast Exam
1/25/08
Breast Exam
-Part of a complete physical exam
-Risk Factors
-Symptoms/Complaints
-1 in 8 women develop breast cancer
*******know risk factors********
[pic]
[pic]
General Questions
■ Do you perform monthly SBE
■ Last mammogram, results
■ History of cancer (patient or family)
■ Breast implants, augmentation
■ Use of birth control pills
■ Use of estrogen replacement therapy
Breast Mass(es)
■ Location
■ Onset (When, How, Change)
■ Does it change with menses?
■ Pain (tenderness) Pattern
■ Skin Lesions, Color variations
■ Nipple Change
Nipple Change
■ Discharge
■ Depression or inversion
-Could be a tumor pulling nipple in
-not problematic if nipples have always been inverted
■ Deviation
■ Discoloration
■ Dermatologic changes
Serous: thin & watery, may appear as stain: intraductal papilloma, carcinoma, b/l-oral contraceptives
Bloody: Malignant intra ductal papillary carcinoma, benign IDP during pregnancy
Milky: Late pregnancy, persistent lactation, pituitary tumor, certain tranquilizers (anti-psychotics)
Change in Skin Over Breast
■ Change in Color or Texture
■ Edema
■ Dimpling, puckering, retraction
■ Discoloration
■ Rash
Inspection: Breast Tissue
■ Sitting & supine
■ Number, size, shape, symmetry, edema, dimpling, redness, thickening of skin, prominent vessels, rashes
■ Slight asymmetry in size is normal
How to Accentuate Changes through Inspection
■ Raise arms over head (stretches pects)
■ Press hands against hips or pressing hands together (contracting the pectoralis muscles)
■ Lean forward with arms outstretched from waist (looks at how breasts hang)
Palpation of Breast Tissue
■ Seated – Bimanual (looking for gross change in tissue density, retraction signs, etc)
■ Supine - Pillow under ipsilateral shoulder (the more comprehensive exam is performed supine)
■ Systematic palpatory approach to assess all breast tissue
■ Optimal exam timeframe: 2-7 days after the onset of menses/month
-follicular phase of menstruation (after 7 days) leads to swelling of the breasts
■ Note consistency of tissue - Normal varies widely with physiologic nodularity noted in most women.
■ Tenderness, masses, skin temperature
■ If mass is noted document accordingly as follows:
Documentation of Breast Mass
■ Location: Clock (preferred method) or Quadrant method w/ distance from nipple (R or L breast)
■ Size: Length, width, thickness
■ Shape: Round, discoid (multiple nodules connected), lobular (fibroadenoma), stellate (irregular – not good)
-Round or discoid could be gross cysts and not problematic
■ Tenderness: Severity (unless significant lymphatic blockage, most cancers are painless)
■ Consistency: Firm, soft (cystic – not as worried), hard (ie pebble – not good)
-Could have calcified lymph nodes
■ Borders: Discrete (good sign) or poorly defined (bad)
■ Mobility: Movable (in what direction) or fixed to overlying skin or underlying fascia or tissue
-Bad sign if fixed
■ Retraction: Presence or absence of dimpling or altered contour
■ If a mass is immobile with the patient relaxed, it is attached to the ribs & intercostal muscles.
■ If a mass becomes fixed when the pt. presses her hands against her hips, the mass is attached to the pectoral fascia.
-Must remove the outer portion of the pec
Nipple & Areola Examination
■ Inspection: 5 D’s
■ Palpation: note thickening, pain
■ Gently compress or strip nipple
■ Note any discharge
Evaluate Axillary Nodes
■ Inspection
■ Lesions: rashes, masses
■ Discoloration (unusual pigmentation)
■ Palpation
■ Location
■ Number
■ Discrete/Matted
■ Size
■ Tenderness
■ Mobility
Lymph Node Assessment
Enlarged axillary nodes from infection, recent immunization, neoplasia, or generalized – check epitrochlear
…
[pic]
Screening Guidelines (NCI)
■ BSE should be started in early 20’s
■ Clinical breast exam about every 3 yrs for women in 20’s & 30’s then yearly for women 40 and older.
■ Screening mammograms every 1-2 yrs starting at age 40 every yr over 50
■ High risks pts personal schedule
Breast Cancer in Males
■ ~1000 men/yr in the US
■ >300 deaths/yr due to metastatic CA
■ Ave age of 59 y.o.
■ 75% painless mass or nodule subareolar or upper outer quadrant
■ M/C site of metastasizes: bone, lung, liver, pleura, lymph node, skin, brain
-----------------------
■ Hobbies (exposure to resp. irritants)
■ Use of alcohol
■ Use of illegal drugs
■ Exercise tolerance
■ Immunizations (TB)
■ Current chest x-rays
■ Morning (smoking)
■ Nocturnal (CHF, postnasal drip)
■ Assoc. w/ eating or drinking (NMS dx of upper esophagus)
■ Inadequate (debility, weakness)
■ Red currant jelly
■ Foul odor (lung abscesses)
■ Pink, blood-tinged (strep or staph pneumonia)
■ Pink, frothy (pulmonary edema)
■ Profuse, colorless (alveolar cell carcinoma)
■ Bloody
■ Pump Failure (CHF)
■ Peak seekers (high altitudes)
■ Psychogenic (anxiety)
■ Poisons
Dyspnea on Exertion (DOE)
■ Grading 1-5 (1st establish a baseline)
■ 1- Excessive activity
■ 2- Moderate activity
■ 3- Mild activity
■ 4- Minimal activity (ie dressing oneself)
■ 5- Rest
■ Peripheral – venous stasis
■ Venous Stasis
■ Exposure to cold
■ Nail beds, nose, lips
■ Cyanosis decreases with warming
Descriptors of Coughing
(table 13-1)
■ Dry, hacking (virus, allergy)
■ Chronic (bronchiectasis)
■ productive
■ Wheezing (asthma, allergy, CHF)
■ Barking (croup – epiglottal dx)
■ Stridor (tracheal obstruction)
Peripheral Signs
■ Posture
■ Facial Expression
■ Use of Accessory Respiration Muscles
■ Clubbing of Nails (pg 376)
■ Cyanosis (central)
Palpation of the Chest/Thorax
■ Tender areas
■ Evaluate skin lesions, abnormal bulges or depressions
■ Determine tracheal position
■ Assess chest expansion (rib excursion)
■ Tactile (vocal) fremitus
■ Estimate level of the diaphragm
■ Decrease:
■ COPD
■ Chest wall weak
■ Pleural effusion
■ Pneumothorax
■ Bronchial Obstruction
■ Thickened Wall
Breath Sounds
■ Auscultation is performed in the across-down-across method
■ 4 Breath Sounds (Note location)
■ Tracheal (harshest – outside chest)
■ Bronchial (over manubrium)
■ Vesicular (periphery)
■ Bronchovesicular (1st and 2nd intercostal spaces)
Ds. of Chest Expansion/Lag (U/L)
■ Chronic fibrotic disease (lung or pleura) – U/L
■ Pleural effusion (fluid accumulates in lowest portion of pleural space)
■ Pneumothorax – air in pleural space
■ Lobar pneumonia – fluid accumulation
■ Pleural Pain (splinting)
■ Unilateral bronchial obstruction
■ Chest Pain
■ Stridor (noisy breathing)
■ Voice changes (vocal cords)
■ Swelling of ankles (dependent edema)
■ Sleep Apnea
-dental problems are the most common cause of lung abscesses
-warm humidity helps to open airways and stop coughing, and then cold air helps to sooth tissues
-in early stage CHF, people cough lightly when in the supine position
-college students are most prone to mycoplasms and viral pneumonias
-TB – later: night sweats, weight loss, fatigue, fever
-asthma – thick mucoid sputum (hard to expectorate)
Accessory resp muscles - contraction of scalenes and SCM
- after scalenes and SCM tires, patient sits with hands on thighs and pushes off a little as breath in
- flaring of nostrils, pursing of lips
- pushing against chest wall to aid in exhaling
More than 5mm of movement of clavicles during resting respiration indicates a problem
*anatomy of respiratory system*
-sternomanubrial angle (2nd rib)
-angulation of ribcage of anterior vs. posterior
-ribs become more horizontal as chest expands
-lungs rise 1-1.5” above inner 1/3 of clavicle
-6th rib on anterior aspect, 10th SP on posterior
-rt/left midclavicular lines (at nipples) & midsternal line
-ant/post axillary lines & midaxillary line
-midspinal line & midscapular lines
-major (oblique fissure) at SP of T3
-descends obliquely down to the 6th rib midclavicular line
-horizontal fissure – from 5th rib to sternum
*-rt middle lobe – from 5th rib (midaxillary) to 4th rib at sternum to 6th rib (midclavicular line)
**know anatomical landmarks of lung lobes
Multiple displaced rib fractures (traumatic flail chest)
-patient should sleep with pillow b/n arm and chest wall (patient should sleep on back, not on side)
Chest Expansion
■ Posterior: 3-4 cm on inspiration @ T10
■ Anterior: Apex - symm. slight motion,
■ Upper lobe ribs 2&3 -- 1-2 cm
■ Lower lobe ribs 5&6 -- 2-3 cm
■ Lateral: Depends on levels
-sighing respiration – anxiety, boredom
-air trapping – classic for COPD
-Cheyne-Stokes – classic for CHF (or drug-induced respiratory depression)
*Flat percussion note: classic for pleural effusion (or “flat to dull”)
*Resonant: normal or ?tumor?
*Hyperresonant: pneumonia
*Dull: classic for lobar pneumonia (with consolidation)
*Tympany: pneumothorax
Symptoms/Complaints
■ Mass or Swelling
■ Pain
■ Nipple Discharge/Deviation
■ Change in Skin over Breast
Breast Pain
■ Location: Unilateral/Bilateral
■ Any Trauma
■ OPPQRST
■ Change In Bra Size
■ Pattern
■ Associated Symptoms
Nipple Discharge
■ Location: Unilateral/Bilateral
■ Onset
■ Describe Change/Discharge
■ Related to Menses
■ Medications/Oral Contraceptives
■ Associated Symptoms
Breast Exam Procedures
-Inspection
-Palpation
-Axillary lymph node evaluation
Inspection: Nipples
■ Size, shape, symmetry
■ Discharge
■ Depression or inversion
■ Deviation
■ Discoloration
■ Dermatologic changes
-caffeine, soft drinks, chocolate, and cheese incr breast swelling & tenderness
-fibrocystic change = benign breast cancer
-radiation to breast tissue leads to increased incidence of mutations occurring
-diagnostic ultrasound is preferred b/c it is better at distinguishing b/n a solid and cystic mass
-if hard, immobile mass or if there are lymph nodes associated with
Table 16.2
-most malignancies occur in the upper outer quadrant
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