health assessment- breast, vascular/lymphatic, head/neck

landmarks

aorta, SVC, IVC, right atrium, right ventricle, pulmonary artery, left ventricle, left atrium

apex

bottom of the heart

base

top of the heart

Point of maximal impulse (PMI)

apex beats/ apical impulse

diastole

relaxation; filling with blood

systolic

contraction; blood is pumped

S1 (lub)

Mitral (M1) and Tricuspid (T1) closes and makes sounds; beginning of systole

S2 (dub)

aortic (A2) and pulmonary (P2) valve closing; end of systole

S2 split

A2 and P2 are heard separately. duuuuub sound

S3

ken-tuck-y I II

physiologic- disappears when patient sits up

pathologic- persists when patient sits up

heard after S2

S4

ten-ne-ssee II I

physiologic- adults > 40, after exercise, no CVD

pathologic- CAD, MI, HTN

before S1

grade I murmur

faint, only heard by expert, no thrill, not heard in all positions

grade II murmur

soft, heard in all positions, no thrill

grade III murmur

moderately loud, no thrill

grade IV murmur

loud and palpable thrill

grade V murmur

very loud, thrill, heard with stethoscope partially off chest

grade VI murmur

loudest, with thrill, heard with steth off of chest

benign murmurs

infants, children/adolescents, athletes, fever, anemia, adult over 50, pregnant

increased velocity over normal aortic and pulmonic valve

grade I-II

P

atrial depolarization

QRS complex

ventricular depolarization

T wave

ventricular repolarization

infants and children

heart starts at 3 weeks of gestation

lungs are nonfunctional, so blood is redirected to heart (strengthens ventricles)

apex in 4th intercostal until 7

pregnancy

increase in blood plasma and RBC

SV increases then returns to normal after 10 days post partum

arterial bp decreases and is lowest during the 2nd trimester

aging adults

systolic bp may increase; diastolic decrease

arrythmias may occur

ECG change

subjective data (heart)

chest pain

dyspnea

cough

fatigue

cyanonsis/pallor

edema

nocturia

past CV history

family CV history

CV risk factor

inspection (heart)

sitting supine

inspection (heart)

varicrose veins

scarring around chest

nail clubbing

JVD

video on measurement

arterial insufficiency

ischemic ulcer

cyanosis

cool and pale

claudication (pain with walking/exercise)

diminished/absent pulse

venous insufficiency

stasis ulcer

present pulse

warm and red/brown

edema

aching pain, worse at end of the day

anklebrachial index

dopler steth and bp cuff

record and divide

use lowest finding

deep vein thrombosis

1-3 cm= mild lymphedema

3-5cm= moderate lymphedema

>5 cm = severe lymphedema

> or= 2cm can occur with DVT

1-2 score is moderate risk

>3 is high probability

palpation

PMI

edema, cap refill, skin temp

pulse

arterial pulses

radial, brachial, femoral, popliteal, doralis pedis, posterior tibial

pulse guidelines

4- bounding

3- stronger than normal

2- normal

1- diminished

0- absent, not palpable

absent pulse

use doppler

capillary refill

should refill within 1-2 seconds

after 2 seconds may indicate issues with perfusion/vasoconstriction

pitting edema

1- 2mm

2- 4mm

3- 6mm

4- 8mm

modified allen test

ulnar and radial arterial pulses

heart sound locations

A- aortic valve

P- pulmonary valve

E- erb’s point

T- tricuspid valve

M- mitral valve

(ape to man)

thrill

palpable

bruit

auscultatory

CV disorders

dizziness, syncope, fatigue, papitations, chest pain, dyspnea

CN VII

facial nerve

inspection (head, scalp, face)

note expression, tics

shape- normocephalic

symmetry

lesions

palpate (head, scalp,face)

contour

mass

depression

tenderness

tension

spans across forhead, can occur in eye

migrainw

tend to be one sided, but can be on both side

cluster

occur behind eye, more common in men

allergic salute and crease

crease forms on nose from children wiping it

allergic shiners & dennie-morgan lines

caput succedaneum

tissue edema, crosses over a suture

goes away after a couple of days

cephalhematoma

well defined and confined (does not cross over suture)

goes away after weeks or months

hydrocephalus

CSF accumulation, increasing intracranial pressure

face looks small compared to head

Ventroperitoneal shunt can divert CSF

plagiocephaly

asymmetry of cranium

treat w tummy time, pt, corrective headwear

craniosynostosis

premature closing of 1 or more cranial sutures

results in malformation

most treated with surgery

trisomy 21

up-slanted eyes

flat nose

protruding, thick tongue

ear dysplasia

short, web neck

small hands with single palmar crease

paget’s disease

localized rapid bone turnover

affects skull, femur, tibia, pelvic bones, vertebrae

acromegaly

excess of growth hormone that results in enlargements of peripheral body parts and soft tissue after fusion of epiphyseal plates occurs without increase in height

cushing’s

excess secretion of ACTH and chronic steroid

develop rounded “moon like” face, red cheeks, hirsutism (beard in women) on upper lid, lower cheeks, and chin; acneiform rash on chest

parkinson

deficiency of dopamine and degeneration of substantia nigra of basal ganglia in brain

produce face that is flat and expressionless, elevated eyebrows, staring gaze, oily skin, drooling

cachectic

accompanies chronic wasting diseases such as cancer, dehydration, and starvation

sunken eyes, hollow cheeks, exhaustion, defeated expression

scleroderma

complication of autoimmune diseases affecting connective tissues of skin, blood vessels, and internal organs

skin and SQ tissue becomes increasingly hard and cannot be pinched up from the underlying structures (looks like botox)

cerebrovascular accident (CVA)

forehead wrinkling intact and symmetrical

palpebral fissure not widened

nasolabial fold is flat

mouth drooping

supranuclear lesion within the brain due to bleeding or ischemia

bell palsy

nasolabial fold is flat

mouth drooping

forehead not wrinkling and asymmetrical

palpebral fissure widened

affects the facial nerve (V)

sternomastoid

rotation and flexion

CN XI

trapezius

shoulders and extend/turn

CN XI

Torticollis

twisted neck

symptom of injury or shortening related to sternomastoid

“wry neck”

inspection (neck)

symmetrical, no masses, full ROM

palpation

trachea midline- slide finger to each side

carotids- one at a time

auscultation

carotids- with bell 3x

thyroid for bruits

thyroid

T3 and T4- synthesis and secretion of hormones that control rate of cellular metabolism

vascular endocrine gland

hyperthyroidism s/s

goiter, nervousness, tachycardia, weight loss, excess sweating, SOB, heat intolerance

hypothyroidism s/s

constipation, fatigue, dry coarse hair, dry skin, weight gain, myxedema

lymphatic locations

lymph node assessment

palpate both sides at same time for comparison

gentle circular motions

deep cervical chains- tilt head to side being examine, press under muscle

supraclavicular- hunch shoulders

lymphadenopathy

enlargement >10cm

infection- tender, enlarged, bilat, firm but freely movable

cancerous- hard, unilateral, nontender, fixed

breast anatomy

quadrants

upper inner

lower inner

upper outer

lower outer

axillary tail of spence

axillary nodes

drain 75% of lymph

central axillary nodes

pectoral nodes

subscapular nodes

lateral nodes

lymph flows up from central to infraclavicular and supraclavicular nodes

supernumerary nipple

where an extra nipple can form

pregnant women

breasts enlarge and feel nodular; nipples are larger

areolae enlarge and become darker; venous pattern is prominent

changes begin in 2nd month of pregnancy

colostrum

precursor for milk, contain same amount of protein and lactose, practically no fat

first few days after birth

rich in antibodies

lactation

1-3 days postpartum

emulsified fat and calcium caseinate

aging

glandular tissue atrophies after menopause

adipose tissue decreases

axillary hair decreases

lactiferous ducts are more palpable; feel firm and stringy bc of fibrosis and calcification

inner structures more palpable

self breast exam

monthly, starting at 20

4-7 days after period

menopause or no cycle- same day each month

screening

ultrasound- younger women bc of dense tissue

family hx, mammogram at least 10 years before onset

american cancer society- begin at 40-44, annual mam from 45-54, biennial mam 55+ or continuation of annual

clinical breast exam

same as self exam

palpate lymph nodes

palpate breast

compress nipple to assess for discharge

large breasts- bimanual technique

mutations

BRCA 1 and BRACA 2

men

1% of breast cancer

gynecomastia

noninflammatory enlargement of male breast tissue

puberty mild and transient

older men- appear due to testosterone deficiency

mastitis

inflammatory

one quad, tender, hot, swollen

treat- antibiotics, heat, frequent feedings

abcess

mastitis worsens

pus pockets

treat- antibiotics, incision/drainage

feed on unaffected side

dimpling

skin retraction from contracting of suspensory ligaments

carcinoma

nipple discharge possible/ deviation possible

usually unilateral

may not always have mass

benign breast disease (fibrocystic breast disease)

makes breast exam difficulty

nodularity

swelling/tenderness

lymphedema

post radiation/axillary node removal

interstitial fluid build up

edema (peau d’orange)

lymph obstruction

pig skin/orange peel

usually suggests CA

fixation

usually CA

fibrosis fixes breast to underlying structure