1/8/08 - Logan Class of December 2011



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

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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)

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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

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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

…

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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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