Logan Class of December 2013
PHYS DX #2 – TEST #1 BOOK NOTES
CH 13 – CHEST AND RESPIRATORY
General Considerations
Cancer of the lung and bronchus is the leading cause of death from cancer in the US in men and women.
Structure and Physiology
Control
Control of breathing comes from the medulla.
Trachea Bifurcation
Trachea bifurcates into left and right bronchi at the level of the fourth and fifth thoracic vertebra.
Right vs. Left Lung
The right bronchus is shorter, wider and straighter than the left bronchus. The right lung has 3 lobes (upper, middle, and lower lobes) vs. the left which has 2 lobes (left).
Pleura
The lungs are covered in a sac called pleura. Visceral pleura cover the parenchyma. The parietal pleura line the chest wall. The two pleural surfaces slide over each other during respiration. The space between the two pleural spaces is the pleural cavity.
Identification Lines
Midsternal Lines – through middle of sternum
Midclavicular Lines – through middle of clavicle
Anterior Axillary Lines – Through anterior axillary folds parallel to midsternal line
Midaxillary Lines – From the vertex of the axilla parallel to the midsternal line
Posterior Axillary Lines – Extends vertically along posterior axillary folds (parallel to midsternal line)
Scapular Lines – Pass through inferior angles of scapulae (parallel to midspinal line)
Midspinal Line – Passes to spinous proceses of vertebrae
Counting
Inferior wing of scapula = 7th rib or 7th interspace
Fissures
Oblique Fissure = Located in both L and R lungs…The fissure begins on the anterior chest at level of 6th rib at midclavicular line and extends laterally upward to 5th rib in midaxillary line & ends at posterior chest T3 Spinous…Right lower lobe is below the right oblique fissure with the upper and middle lobes superior the right oblique fissure…The left upper lobe is above the fissure.
Horizontal Fissure = only on the right lung and divides right upper lobe from right middle lobe. The horizontal fissure extends from 4th rib at sternal border to 5th rib at midaxillary line.
Lung Dimensions and Landmarks
Extends above the clavicles 3-4 cm. The inferior parts extend to 6th rib at midclavicular line and 8th rib at midaxillary line when viewing the patient from the anterior. On the posterior side the lungs extend between T9 and T12.
Carina = behind the Angle of Louis and located at T4 on the posterior chest/
Right hemidiaphragm = 5th Rib anteriorly and T9 posteriorly.
Liver = on the right side making the right hemidiaphragm higher up than the left.
Review of Specific Symptoms
Cough
Most common symptoms of lung disease. Coughing is a protective mechanism. Persistent coughs require more information. Coughing is coordinated, forced air expiration interrupted by repeated closure of the glottis. High pressure is generated and then when the glottis opens the explosive push of air occurs producing the cough. Smoking is the most common cause of chronic cough. Smoking cough’s is more evident in the morning as the cough clears the respiratory passages.
Table 13-1 Coughing Descriptors
Dry, hacking = Viral infection, interstitial lung disease, tumor, allergies, anxiety
Chronic, productive = Bronchiectasis, chronic bronchitis, abscess, bacterial pneumonia, TB
Wheezing = Bronchospasm, asthma, allergies, CHF
Barking = Epiglottal disease (croup)
Stridor = Tracheal obstruction
Morning = Smoking
Nocturnal = Postnasal drip, CHF
Eating or Drinking = neuromuscular disease of upper esophagus
Inadequate = debility, weakness
Sputum Production
An increase in the quantity of sputum production is the earliest manifestation of bronchitis. Mucoid sputum is odorless, transparent, and white/gray. Purulent sputum contains pus and may be yellow, green or red.
Hemoptysis
The coughing up of blood. Bronchitis is the most common cause of hemoptysis. Other common diseases that involve coughing of blood include bronchiectasis and bronchigenic carcinoma
Coughing up clots of blood is extremely important and indicates serious illness. This is indicative of lung lesion, tumor of the lung, cardiac disease, or pulmonary embolism.
Coughing of blood can also come from DVT (deep vein thrombosis) or pulmonary embolism. Women on oral contraceptives, passengers on long flights are at greater risk for DVT and PE’s. Hemoptysis occurs when pulmonary emboli result in infarction and necrosis of parenchyma.
Recurrent hemoptysis can be from bronchiectasis, TB or mitral stenosis.
Sputum Color
Rust = Pneumoccal Pneumonia
Pink & Frothy = Pulmonary Edema
Table 13-2 – Appearance of Sputum
Mucoid = Asthma, tumors, TB, emphysema, pneumonia
Mucopurulent = Asthma, tumors, TB, emphysema, pneumonia
Yellow-Green, purulent = Bronchiectasis, Chronic Bronchitis
Rust-colored, purulent = Pneumococcal
Red Currant Jelly = Klebsiella Pneumoniae
Foul Odor = Lung Abscess
Pink, Blood Tinged = Strept Pneumoniae or Staph Pneumoniae
Gravel = Broncholithiasis
Pink, frothy = Pulmonary Edema
Profuse, colorless = Alveolar cell carcinoma
Bloody = Emobli, bronchiectasis, abscess, TB, tumor, cardiac causes, bleeding disorders
Dyspnea
Shortness of breath. Dyspnea is found in many conditions. Never assume that a patient with rapid respiratory rate is dyspneic.
1. Paroxysmal Nocturnal Dyspnea = Sudden onset of shortness of breath at night during sleep. The remedy is to sit upright or stand upright.
2. Orthopnea = Difficulty breathing while flat (remedy is to add pillows)
3. Platypnea = Difficulty while sitting up (remedy is to lay down)
4. Trepopnea = Patients are more comfortable lying on one side and have difficulty lying on opposite side.
It is also important to ask about exercise tolerance and industrial exposure.
Table 13-4 Positional Dyspnea
Orthopnea = CHF, Mitral Valve Disease, Severe Asthma (rare), Emphysema (rare), Chronic Bronchitis (rare), Neurologic Diseases (rare)
Trepopnea = CHF
Platypnea = Post-pneumonectomy, neurological diseases, cirrhosis, hypovolemia
Wheezing
Abnormally high pitched noise resulting from a partially obstructed airway. Wheezing is usually present with expiration during bronchoconstriction. Causes are: bronchospasm, mucosal edema, loss of elastic support, tortuosity of airway, asthma (causing bronchospasm), obstruction or airway by aspirated foreign body or secretion, tumor (obstructing the airway).
Asthma is associated with wheezing, but not all wheezing is asthma.
A silent chest in a patient with an acute asthma attack is a bad sign as it means the condition is worsening.
Cyanosis
Central Cyanosis = Occurs due to inadequate gas exchange in the lungs impacting arterial oxygenation. Often the cause of central cyanosis is intracardiac shunt where mixed venous gases bypass the lungs. The lips, mouth and mucus membranes become blue. Cyanosis of the nails with warm hands suggests central cyanosis. Central cyanosis occurs when oxygen saturation falls below 80%. Involves the skin and mucus membranes and does not disappear with warming of the area. Exercise worsens central cyanosis. Clubbing is often seen with central cyanosis.
Peripheral Cyanosis = Excessive extraction of oxygen in the periphery. Due to increased extraction in the periphery with states of low cardiac output. It is often seen in cooler areas like the nail beds and outer surfaces of the lips. Peripheral cyanosis disappears as an area is warmed.
Acute Cyanosis = Can develop in acute respiratory conditions
Congenital Cyanosis = Develops from birth
Chest Pain
Involves the chest wall or parietal pleura. Pleuritic pain involves inflammation of the parietal pleura that is sharp, stabbing, felt during inspiration, localized to one side and may involve patient splinting (to avoid pain). Chest wall pain may be due to acute dilatation of the pulmonary artery mimicking angina pectoris. Chest pain is also involved in cardiac conditions, so make sure to distinguish between the two with your exam.
Sleep Apnea
Excessive daytime fatigue, sleepiness, disruptive snoring, episodes of upper airway obstruction during sleep and nocturnal hypoxemia. The patient struggles to breathe against a closed airway as the pharynx collapses. This results in hypoxemia. The patient awakens from sleep contracting the posterior pharynx muscles and opens the airway causing snoring as air rushes in. The events repeat. Daytime fatigue due to hypoxemia occurs.
The presence of snoring, sleepiness and tiredness suggests a diagnosis of sleep apnea.
Other symptoms
Stridor = Noisy breathing…associated with obstruction of a major bronchus with aspiration.
Voice changes = inflammation of vocal cords or interference with the recurrent laryngeal nerve
Swelling of the ankles = Dependent edema associates with right heart failure, renal disease, liver disease or obstruction of venous flow.
Impact of Lung Disease on the Patient
COPD
Emphysema and chronic bronchitis that are characterized by slow progression, obstruction of airflow, destruction of lung parenchyma.
1. Emphysema = Pink puffers…thin, weak, severe dyspnea, little cough and little sputum production
2. Chronic Bronchitis = Blue bloaters…cyanotic, productive cough, short and stocky stature
Asthma
Emotional situations can cause an attack. The attempt to suppress the emotion, rather than the emotion itself may be the culprit. Asthmatics need continuing medical and psychological support after an acute attack. Often if they receive one form of treatment without the other a vicious circle can persist.
Physical Exam
Includes inspection, palpation, percussion, and auscultation of the anterior and posterior chest. For the posterior chest, the patient’s arms are folded. For the anterior chest, the patient is lying supine.
General Assessment – Inspection
Some things to inspect:
1. Acute Distress
2. Nasal Flaring
3. Pursed Lips
4. Stridor or wheezing (related to obstruction)
5. Cyanosis
6. Posture = Patients with obstruction often use shoulder and neck muscles to aid respiration. Bedridden patients can use their latissimus dorsi to overcome increase resistance during expiration. Orthopnea patients remain seated or lie on pillows to breathe
7. Neck inspection for accessory muscles = Use of accessory muscles indicates an early sign of airway obstruction. The SCM and trapezius assist in ventilation by raising the clavicle and anterior chest to increase volume and create negative pressure)
8. Retraction of supraclavicular fossa and intercostal muscles
9. Upward motion of the clavicle greater than 5 mm during respiration – Associated with severe obstructive lung disease
10. Inspect the chest
a). COPD = Increased AP diameter that often equals the lateral diameter (barrel chest). The ribs lose their 45 angle and become more horizontal
b). Flail Chest = Seen with rib fractures as the one side of the chest wall moves more inward during inspiration
c). Kyphosoliosis = Restricts chest and lung expansion
d). Pectus Excavatum = Funnel chest, with depression of the sternum that can cause restrictive lung problems. This condition is linked to mitral valve prolapse.
e). Pectus Carinatum = Pigeon breast, occurring from anterior protrusion of the sternum, that does not compromise ventilation.
11. Assess the Respiratory Rate and Pattern = 30 seconds and multiply by 2. Normally 10-14 breaths per minute (Swartz) vs. 10-20 (Manello).
a). Hyperpnea = Increased depth of breathing associated with metabolic acidosis (Kussmaul’s breathing)
Figure 13-10 – Patterns of Abnormal Breathing
Apnea = Absence of breathing…Often the cause of cardiac arrest
Biot’s = Irregular breathing with long periods of apnea…The cause is increased intracranial pressure, drug induced respiratory depression, brain damage (at medullary level)
Cheyne-Stokes = Irregular breathing with intermittent periods of increases and decreased rates and depths of breaths alternating with periods of apnea…the causes are drug induced respiratory depression, congestive heart failure, and brain damage (at the cerebral level)
Kussmaul’s = Fast and deep breathing…The cause is metabolic acidosis
12. Inspect the hands for clubbing (loss of the angle between the nail and terminal phalanx)…Clubbing is associated with intrathoracic tumors, mixed venous to arterial shunts, COPD, and chronic hepatic fibrosis. Arterial dessaturation is listed as the pathologic process leading to clubbing
13. Inspect the Posterior Chest then follow inspection with palpation (tenderness, chest excursion symmetry, tactile fremitus), percussion and auscultation
14. Inspect the Anterior Chest then follow inspection with palpation, percussion, and auscultation
Posterior Chest
1. Inspection = See above
2. Palpation =Tenderness, Posterior Excursion, Tactile Fremitus…
a. Excursion = Hands on the back with thumbs parallel to midline at the tenth rib level pulling skin to midline. The patient inhales and doctor follows movement with hands comparing side to side. The doctor looks for symmetry. Lack of symmetry indicates local pulmonary problems.
b. Tactile Fremitus = Provides information about the density of the underlying lung tissue and chest cavity. Consolidation increase density of the lung making it more solid and increasing the tactile fremitus. Excess fat tissue on the chest, air in the chest cavity, fluid in the chest cavity, overexpansion of the lung all decrease Tactile Fremitus. Schwartz recommends saying the word 99 because it has “good vibratory tone.” Schwartz recommends that tactile fremitus is evaluates with the ulnar part of the hand moving side to side and top to bottom in 6 location. Schwartz also states that the fingertips are an alternate method that can be use.
Table 13-5
Increased Tactile Fremitus = Consolidation
Decreased Tactile Fremitus = Unilateral (Pneumothorax, pleural effusion, bronchial obstruction, atelectasis)…Bilateral (COPD, Chest wall thickening – muscle or fat)
3. Percussion = Tapping on the chest wall is transmitted to the underlying tissues, reflected and picked up by tactile or auditory sensations. The depth to which percussion affects is 5-6 cm. Air-tissue ratio becomes important in assessing the result. The posterior chest should be percussed above, between and below the scapula in the intercostal spaces.
a). Dull = Solid organ (liver and heart), low amplitude short duration without resonance…Lungs can become dull when they are filled with fluid as occurring in pneumonia (Pneumonia will make the normal lung sound of resonance sound dull).
b). Resonant = Air within a tissue, producing a higher amplitude, lower pitched note (lung)
c). Tympanic = High pitched, hollow quality note (stomach)
d). Flat = Flat high pitched note (muscle)
e). Hyperresonance = Occurs in lung with decreased density (emphysema)…Low pitched, hollow-quality, sustained note mimicking tympany
f). Diaphragmatic Excursion = Detects diaphragmatic movement from inspiration to expiration. Have the patient inhale and hold, filling their lungs with air. Percuss down the spine till dullness is heard over the liver and below the lowest part of the right lung. Mark this spot. Have the patient exhale and hold it, percussing down till dullness of the liver is heard, below the lowest part of the right lung. Mark this spot. With expiration the dullness should move superior as the lung and diaphragm contract moving the lung and liver upwards. The difference is normally 4-5 cm. Emphysema patients have less motion. Phrenic nerve palsy patients have absent motion.
4. Auscultation= Bell is used to detect low pitched sounds and should be loosely used on the skin…Diaphragm is used to detect higher pitched sounds and needs to be firmly applied to the skin. Do not listen through clothing as the stethoscope must always contact skin. The patient breathes in and out through the mouth. Very soft breath sounds are called distant sounds. Distant sounds are found in emphysema.
a). Types of Sounds
1). Tracheal = Harsh, loud, high pitched and should only be heard over the trachea. The sounds are equal in length from inspiration to expiration (1:1). The sound does not represent pathology or lung problems when hear in the normal location over the trachea
2). Bronchial = Loud, high pitched sounds…Sounds like air filling a tube. Expiration is longer and louder than inspiration. There is a clear pause between inspiration and expiration. Sounds are heard over the manubrium
3). Bronchovesicular = Mixture of bronchial and vesicular sounds. Inspiration and expiration are equal in length (1:1). Heard in the first and second interspaces on the anterior chest and between the scapulae on the posterior chest. This area overlies the carina and mainstem bronchi.
4). Vesicular = Soft, low pitched heard over most lung fields. Inspiration is longer than expiration. Expiration is often softer and may be inaudible.
Figure 13-9
Tracheal = Very loud intensity, Very high pitch, 1:1 Inspiration to expiration ration, Harsh Sound, Normal location in the extrathoracic area.
Bronchial = Loud intensity, High pitch, 1:3 Inspiration to expiration ratio, tubular description, normal location over the manubrium.
Bronchovesicular = Moderate intensity, moderate pitch, 1:1 Inspiration to expiration ratio, Rustling but tubular description…Normal location over mainstem bronchi
Vesicular = Soft intensity, low pitch, 3:1 inspiration to expiration ratio, gentle rustling, normal location over peripheral lung fields
Anterior Chest
1. Inspection of trachea: This is done with the patient seated. All other tests are done with the patient supine. Evaluate tracheal position by placing index finger in suprasternal notch and moving to feel tracheal location. Repeat on the other side and compare. The space between trachea and clavicle should be equal on each side. Deviation could indicate mass. .
2. Palpation = If the patient is a woman have them elevate and move their breasts during palpation, percussion and auscultation.
a). Tactile Fremitus = Assessed in the supraclavicular fossa and in the anterior interspaces comparing side to side working down the chest.
3). Percussion = Percuss the supraclavicular fossa, axillae, and anterior interspaces. There may be dullness with percussion over the heart, located in the third to fifth intercostal spaces to the left of the sternum. The axillae are percussed, because assessment of the upper lobes occurs there
4). Auscultate = Supraclavicular fossae, axillae, anterior chest interspaces
Clinicopathologic Correlations
Adventitious sounds = Abnormal Breath sounds like crackles, wheezes, rhonchi, and pleural rubs.
Crackles
Short, discontinuous nonmusical sounds heard mostly during inspiration. Crackles are also known as rales or crepitation. Crackles are caused by opening of collapses distal airways and alveoli. The equalization or pressure from airway opening causes a crackle. The sound mimics hair rubbing together or velcro. The most common cause is pulmonary edema, congestive heart failure and pulmonary fibrosis.
Wheezes
Continuous, musical, high pitched sounds heard mostly during expiration. The cause is airflow through narrow bronchi. Narrowing may occur from fluid (swelling, secretions), spasm, tumor or foreign body. Wheezes are commonly associated with asthmatic bronchospasm.
Rhonchi
Lower pitched, sonorous lung sounds common with mucus plugs and poor movement of airway secretions.
Pleural Rub
Grating sound produced by pleural motion and frictional resistance. This is heard at the end of inspiration and the beginning of expiration. The sound is similar to leather creaking. Pleural cells are thickened and roughened by inflammation, neoplasm, or fibrin deposits.
Table 13-7 Adventitious Sounds
Crackle = Termed = Rale or Crepitation, Mechanism = excess airway secretions, Causes = bronchitis, respiratory infections, pulmonary edema, atelectasis, fibrosis, and congestive heart failure
Wheeze = Termed = sibilant rale, musical rale, sonorous rale, low-pitched wheeze, Mechanism = rapid airflow through obstructed airway, Causes = Asthma, pulmonary edema, bronchitis, congestive heart failure.
Rhonchus = Mechanism = transient airway plugging, Causes = bronchitis
Pleural Rub = Mechanism = inflammation of the pleura, Causes = pneumonia, pulmonary infarction
Egophony
Increased intensity of sound in the lungs when comparing side to side and top to bottom. The patient says “eeee”. Change in auscultation from “eeee” to “aaa” would indicate lung consolidation (possible pneumonia or pleural effusion).
Whispered pectoriloquy
Intensification of whispered sound…Indicates consolidation….Ex. Whispered 1, 2, 3 auscultates as intense/loud sounding 1, 2, 3
Bronchophony
Presence indicates consolidation in the lungs…Ex. “99” in normal voice auscultates as intense/loud “99”
Table 13-8…Common Conditions associated with Dyspnea
1. Asthma = Dyspnea is episodic, with the patient symptom free between attacks. Other symptoms are wheezing, chest pain, and productive cough.
2. Pneumonia = Dyspnea has insidious onset. Other symptoms are cough
3. Pulmonary Edema = Dyspnea is abrupt. Other symptoms are tachypnea, cough, orthopnea, and nocturnal dyspnea.
4. Pulmonary Fibrosis = Dyspnea is progressive. Other symptoms re tachypnea and dry cough.
5. Pneumonia = Dyspnea is exertional. Other symptoms are productive cough, pleuritic pain.
6. Pneumothorax = Dyspnea is sudden, moderate to severe. Other symptoms are sudden pleuritic pain.
7. Emphysema = Dyspnea is insidious onset and severe. Other symptoms are cough as the disease progresses.
8. Chronic Bronchitis = Dyspnea occurs as disease progresses with infection. Other symptoms are cough as the disease progresses.
9. Obesity = Dyspnea is exertional.
Table 13-9 Differentiation of Common Pulmonary Conditions
1. Asthma = Vital signs = tachypnea, tachycardia…Inspection = dyspnea, use of accessory muscles, possible cyanosis and hyperinflation…Palpation = Often normal, decreased fremitus…Percussion…Often normal, hyper resonant, low diaphragm…Auscultation = Prolonged expiration, wheezes, decreased lung sounds.
2. Emphysema = Vital signs = stable…Inspection = Increased AP diameter, use of accessory muscles, thin individual…Palpation = Decreased tactile fremitus…Percussion = Increased resonance; decreased excursion of the diaphragm…Auscultation = decreased lung sounds, decreased vocal fremitus
3. Chronic Bronchitis = Vital Signs = Tachycardia…Inspection = Possible cyanosis, short, stocky individual…Palpation = often normal…Percussion = Increased resonance, decreased excursion of diaphragm…Auscultation = Decreased lung sounds, decreased vocal fremitus
4. Pneumonia = Vital signs = Tachycardia, fever, tachypnea…Inspection = possible cyanosis, possible splitting on affected side…Palpation = Increased tactile fremitus…Percussion = Dull…Auscultation = late crackles, bronchial breath sounds
5. Pulmonary Embolism = Vital Signs = tachycardia, tachypnea…Inspection = often normal…Palpation = usually normal…Percussion = Usually normal…Auscultation = Usually normal (*** Most things normal, except vital signs ***)
6. Pulmonary Edema = Vital signs = tachycardia, tachypnea…Inspection = possible signs of elevated right heart pressures…Palpation = Often normal…Percussion = Often normal…Auscultation = Early crackles, wheezes
7. Pneumothorax = Vital Signs = Tachypnea, Tachycardia…Inspection = Often normal, lag on affected side…Palpation = absent fremitus; trachea shifted to other side…Percussion = Hyper resonant…Auscultation = Absent Breath sounds
8. Pleural Effusion = Vital Signs = Tachypnea, tachycardia…Inspection = Often normal, lag of affected side…Palpation = decreased fremitus, trachea shifted to other side…Percussion = Dullness…Auscultation = Absent breath sounds (*** effusion has tachycardia as a vital sign vs. atelectasis which presents the same except for tachycardia *** )
9. Atelectasis = Vital Signs = Tachypnea…Inspection = Often normal, lag on affected side…Palpation = Decreased fremitus, trachea shifted to same side…Percussion = Dullness…Auscultation = Absent breath sounds
CH 16 – THE BREAST
General Considerations
1 in 8 American women will develop breast cancer. Breast cancer is the most malignant disease in women and second most common cause of cancer death in women. The incidence of breast cancer is highest in American women than in women of other countries. Family history of breast cancer increases the risk. Risk is also dependent on when the woman gets breast cancer (premenopause vs. post menopause) and if one or both breast contracts the cancer. The familial risk is highest among women who have breast cancer in both breasts pre-menopause. Other factors include menarche before the age of 12 and women who had their first child after 30 years of age.
Most breast cancers are painless masses noticed during physical examination. The earlier the diagnosis the better the prognosis. Screening is done by breast physical exam, breast self-exam and mammography. Mammography is the most sensitive method for the detection of breast cancer and reduces the mortality rate.
Summary of Breast Cancer Risk Factors
American Women
Family History
Post menopause (higher risk) vs. Pre-menopause (lower risk)
Both Breasts (more likely for 1st generation women to contract breast cancer) vs. 1 Breast Involved
Menarche before Age 12
Women having 1st child after 30
Structure and Physiology
General Breast Information
The breast extends from the second or third rib to the sixth or seventh rib from the sternal edge to the anterior axillary line. The tail of the breast extends into the axilla and is thicker than other breast areas. The upper outer quadrant of the breast contains a majority of the mamillary tissue and is a common site of neoplasia.
The breast has extensive venous and lymphatic drainage. Most of the lymphatic drainage empties into the nodes in the axilla.
Factors that affect the Breast
1. Growth and Aging 2. Menstrual Cycle 3. Pregnancy
General Breast Development
Nodularity, density and fullness of adult breasts are dependent mostly on amount of adipose tissue. Women who nurse have softer, less nodular breast. The size of the breast is unrelated to nursing and is mostly dependent on amount of adipose tissue. With menopause, the breasts decrease in size and become less dense. There is a decrease in elastic tissue with aging in women.
Prior to menstruation (3-5 days), the breasts become engorged with an increase in size, density and nodularity. The breasts are also more sensitive then. This is a bad time to make a diagnosis of breast disorder due to the normal increase density and nodularity of breast at/near menstruation.
During pregnancy, breasts become fuller and firmer along with darkening of the aerial and nipple enlargement. Women secrete colustrum during the third trimester of pregnancy.
Neuroendocrine Control of Milk Production
1. Suckling stimulates the hypothalamus
2. Hypothalamus stimulates the ant. pituitary to secrete Prolactin
3. Prolactin acts on the breast to produce milk
1. Suckling stimulates the hypothalamus
2. Hypothalamus stimulates the post. Pituitary to produce Oxytocin
3. Oxytocin stimulates the muscles cells around the glandular tissue to contract and eject/let down milk.
Milk Line
An embryological development line runs from axilla through the breast, through the nipple, down the abdomen and to the inguinal region. This line may yield an accessory breast or nipple. There may be 1 or 2 accessory breasts or nipples. The axilla is the most common spot for an accessory structure. The condition is often bilateral and often has no clinical implications.
Review of Specific Symptoms
It is very important to assess: 1). Mass or Swelling 2). Pain 3). Nipple Discharge 4). Change in skin over breast
Mass or Swelling
Neoplasm (likely) = Mass/Swelling, Nipple Discharge, Nipple Inversion, Skin changes over a mass
Physiologic Nodularity (Neoplasm Unlikely) = Premenstrual and menstrual parts of the cycle, with associated pain
Pain
Pain is often part of a woman’s normal physiologic cycle. Other causes of pain are enlarging cysts (rapid enlargement). Typically, breast pain is uncommon to cancer, but do not delay evaluation of a painful breast mass.
Nipple Discharge
Most common type of nipple discharge is serous and bloody. Serous is thin, watery and can appear yellowish. Causes of serous discharge include intraductal papilloma, oral contraceptives and breast carcinoma. Bloody discharge is associated with intraductal papilloma that is common among pregnant women, menstruating women, and malignant intraductal papillary carcinoma.
The presence of discharge is more important than the character.
Persistent lactation = Galactorrhea…Can result from massive hemorrhage during childbirth and cause pituitary necrosis.
Changes in Skin over Breast
A change in the color, texture of the skin of the breast or areola is an important finding of breast carcinoma. Dimpling, puckering or scaliness warrants further investigation. Prominent pores and edema indicates malignancy.
Peau de orange = Orange peel appearance…Characterized by prominent pores and edema. Edema occurs due to lymphatic blockage
Impact of Breast Disease on the Patient
Important considerations for women with breast cancer and post mastectomy include depression, sexual inhibition, sexual frustration, fear (of cancer returning and disfigurement), and low self esteem.
Physical Examination
Includes inspection, axillary examination and palpation. The exam is performed sitting up and lying down. While seated, inspection of the breasts and palpation of the lymph nodes are done. While lying, the entire breast is palpated with firm pressure using the pulp of the finger.
The breast is divided into four quadrants through the nipple. This is done to assist palpation, inspection and identify sights of lesions.
Inspect the Breasts
A patient has arms to the side. Dr. looks for changes to contour, symmetry, size, shape, color, edema, inflammation, dimpling. Nipples are inspected for size, shape, inversion, eversion, discharge, symmetry and bulging.
Signs of Carcinoma Evident on Inspection
1. Edema = Edema over the skin of the breast that sits upon malignancy can present as peau d’orange.
2. Inflammation = may indicate infection or inflammatory carcinoma.
3. Dimpling = Indicates retraction phenomena due to underlying neoplasm…Skin retraction is associated with malignancy by placing traction on Cooper’s ligaments.
4. Nipple Inversion = Shortened mammary duct that can invert the nipple and is a sign of carcinoma
5. Dimpling of the breast with bloody nipple discharge = A sign of carcinoma
6. Paget’s Disease = Unilateral, eczematous lesion with eroded skin that is associated with underlying invasive or intraductal carcinoma
Inspect the Breasts in Various Positions
Different postures are used to check for retraction. Assuming these positions make the retraction more evident. Postures: 1. Arms to sides 2. Arms over head 3. Arms pressed to hips with pecs tightened (may make dimpling more evident due to pec contraction) 4. Bend at the waist (breasts hang free)
Axillary Exam
Dr. supports the patient’s forearm, patient relaxes their pecs, and dr. uses finer tips to palpate the axillary, clavicular and subclavian areas. The dr. uses small circular motions.
Palpation
Patient lies down and doctor palpates one side at a time from the same side. The arms are either to the side (small breasted women) or above their head (large breasted women).
Palpate the Breast
Methods of Palpation: 1. Spokes of a Wheel 2. Concentric circle 3. Vertical Strip Method
1. Spokes of a Wheel: Dr. Begins at the Nipple and palpates outward moving clockwise or counterclockwise
2. Concentric Circles: Dr. Starts at the nipple and palpates outward using concentric circles increasing in size
3. Strip Method: Breast is divided into vertical strips with the doctor using pads of the fingers palpating up and down with small dime-sized circles that overlap. This method is listed as the best overall, best for breast self-exam and most time consuming
Describe the Findings
Size, Shape, Delimitation (Are the borders sharp – cyst or diffuse – cancer), Consistency (hard – cancer or elastic – cyst), Mobility (moveable – benign tumor or cyst….non moveable – carcinoma)
Evaluate for Retraction Phenomena
Check for molding of the skin. Molding is associated with cancer and presents with marked dimpling along with lymphedema.
Palpate the Subareolar Area
Examine the Nipple
Check for retraction, fissure, scaling, and discharge. Discharge involves either the doctor or patient (preferably the patient) compressing the nipple.
Breast Self Exam
Women should start this practice at 20 years of age with monthly exams. The best time to perform a self exam is 2-3 days to a week after the end of the menstrual period. The breasts are less tender and swollen. Women on oral contraceptives are recommended to do the self exam each month on the day they begin a new package of pills.
If a lump is discovered, a woman should seek medical attention; however, most lumps are no cancer.
Breast Self Exam Guidelines
1. Standing: Women stand with arms to side in front of mirror. She inspects both breasts for dimpling, puckering, discharge or scaling of skin.
2. Arms Raised: She raises arms, clasping arms behind head, looking for changes.
3. Arms on Hips: Bend slightly forward and pull shoulders and elbows forward.
4. Raise arms and Palpate: Using the pads of your fingers palpate the breast of the arm that is raised. Move in small circles around the breast. Make sure to palpate the tissue between the breast and underarm.
5. Squeeze the Nipple: Look for discharge
6. Repeat the palpation with arm raised while lying down (use a pillow for comfort)
7. Repeat on the other side.
Common problems: 1. Not performed 2. Sitting/Standing and Lying down should both be done 3. Forgetting to use a pillow 4. Arm examined needs to be raised above the head and relaxed
Male Breast
Gynecomastia = Enlargement of male breasts that can occur with aging or drug related (usually due to cancer drugs…
The most common manifestation of male breast cancer is painless, firm, subareolar mass or mass in the upper outer quadrant.
The most common sites for both men and women for breast cancer to metastasize to are the bone, lung, liver, pleura, lymph nodes, skin and viscera.
Clinicopathologic Correlations
Breast Cancer
Evidence suggests that DNA repair defects are factors in cancer especially the tumor suppressor genes and breast susceptibility genes (BRCA1 and BRCA2). These genes keep cellular growth in check. These genes code for proteins that are associated with early onset breast and ovarian cancer in females and prostate cancer in men.
Finding a breast mass with palpation requires a biopsy (even with a normal mammogram). Breast palpation has a lower true + (less sensitive) than a mammogram as there is many false negatives with breast palpation. A lump detected by palpation and physical exam carries a 20% chance for cancer.
Benign Lesions = Freely mobile, well delimited borders, soft, cystic…This is the typical presentation, but malignant breast cancer may even show lesions that are freely mobile, well-delimited and soft or cystic.
Cancerous Lesions = Fixed, irregular borders and hard….This is the typical presentation. The more factors the mass has the greater the chance it is malignant….Ex. A fixed lesion is less likely to be cancerous, than a fixed, irregular shaped lesion.
Table 16-1 – Limitations of Physical Exam and Mammography
Physical Exam: Sensitivity (true +) = 24%....Specificity (True -) = 95%
Mammography: Sensitivity (true +) = 62%...Specificity (True -) = 90%
Differentiation of Breast Masses
Cystic Disease: Age = 25-60… Number = One or more in #...Shape = Round Shape…Consistency = Elastic, soft to hard …Delimitation = Well delimited…Mobility = Mobile…Tenderness = Tenderness present…Skin Retraction = Absent
Benign Adenoma: Age = 10-55…Number = One…Shape = Round…Consistency = Firm…Delimitation = Well delimited…Mobility = Mobile…Tenderness = Absent…Skin retraction = Absent
Malignant Tumor: Age = 25-85…Number = One…Shape = Irregular…Consistency = Stony hard…Delimitation = Poorly Delimited…Mobility = Fixed…Tenderness = Absent…Skin retraction = Present
Characteristics of Breast Masses Suspect for Cancer
Fixed Mass: Sensitivity (true +) = 40%…Specificity (true -) = 90%
Poorly delimited mass: Sensitivity = 60%...Specificity = 90%
Hard mass: Sensitivity = 62%...Specificity = 90%
Screening Guidelines for Breast Cancer-- Mammograms
1. Women should receive mammograms every 1-2 years at age 40.
2. Women should receive yearly mammograms at age 50.
Mammograms include 2 views (craniocaudal and oblique angled view). Mammograms help to detect 85% of all cancers. About 10-15% of cancers are missed on mammogram because either the tumor is too small, located in a hard to view area, or obscured by radiographic shadows.
3. If a mammogram is +, further imaging is warranted (spot view mammogram, diagnostic ultrasound, or other test).
4. If the additional radiograph is +, the patient is referred for a biopsy.
Screening Procedures for Breast Cancer – Physical Exam
1. clinical breast exams should be part of a woman’s care ever 3 years in her 20’s and 30’s and every year for women over 40.
2. Women should know what their breasts normally feel like by frequent breast self exam taught to them in their 20’s by their doctors. Any changes should be reported immediately.
3. Women with increased risk should have earlier mammograms, additional tests and more frequent exams.
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