311: Exam 4

most common location of breast tumors

Upper outer quadrant of the breast, near the axillary tail of Spence.

Breast Exam Variability during the month

Hormonal changes during the menstrual cycle cause breast tissue to feel different; tenderness and lumpiness may increase before menstruation.

higher risk of breast cancer

Older age, family history, BRCA1/BRCA2 gene mutations, early menarche/late menopause, nulliparity, hormone replacement therapy, obesity, alcohol use.

important factors when documenting breast lumps

Location, size, shape, consistency, mobility, tenderness, and skin changes.

importance of self-breast exams

helps in early detection of abnormalities, including lumps of skin changes that may indicate cancer

typical characteristics of a cancerous breast mass

hard, non-mobile, irregular borders, non-tender, often unilateral

causes of nipple discharge

Pregnancy, lactation, benign papilloma, duct ectasia, infection, breast cancer, hormonal imbalance

differences in the left lung

two-lobes (superior and inferior) instead of three; contains the cardiac notch to accommodate the heart

location of the lung apices

extend 3-4 cm above the clavicles

expected lung assessment findings

resonant percussion, vascular breath sounds over most lung fields, clear to auscultation

muscles used in respiration

Diaphragm, intercostal muscles, accessory muscles (sternocleidomastoid, scalene, trapezius in labored breathing

origin of tactile fremitus

Vibrations from vocal cords transmitted through the lung tissue

purpose of tactile fremitus assessment

Detect areas of increased or decreased vibration, indicating lung consolidation or obstruction

inspection of the anterior chest

Looking for symmetry, shape, respiratory effort, accessory muscle use, and skin changes

correct chest auscultation technique

Use diaphragm of stethoscope, auscultate systematically in a ladder pattern, compare bilaterally

timing of crackles/wheezes

Crackles in pneumonia, CHF; wheezes in asthma, COPD

causes of unequal chest expansion

Pneumothorax, pleural effusion, atelectasis, rib fracture

chest characteristics in COPD

Barrel chest, use of accessory muscles, pursed-lip breathing, tripod position

confirming systemic lung expansion

place hands on lower posterior ribs, thumbs should move equally apart with deep inspiration

risk factors for COPD

Smoking, air pollution, occupational exposure, genetic predisposition (Alpha-1 antitrypsin deficiency)

direction of blood flow in the heart

• Deoxygenated blood: Vena cava → Right atrium → Tricuspid valve → Right ventricle → Pulmonary valve → Pulmonary arteries → Lungs

• Oxygenated blood: Pulmonary veins → Left atrium → Mitral valve → Left ventricle → Aortic valve → Aorta → Body

best locations to hear valve closures

• Base of the heart: Aortic and pulmonic valve closure (S2)

Apex of the heart: Mitral and tricuspid valve closure (S1)

heart disease risk factors

Hypertension, smoking, diabetes, high cholesterol, obesity, sedentary lifestyle, family history

assessing carotid arteries

Palpate one at a time, auscultate for bruits using the bell of the stethoscope

auscultating heart sounds

Use diaphragm, listen at 4 main valve areas in a systematic pattern

best locations for S1 and S2

• S1 (lub): Loudest at the apex (mitral area).

S2 (dub): Loudest at the base (aortic/pulmonic area

palpating/auscultating apical pulse

Using diaphragm in the 5th intercostal space, mid clavicular line

correct technique for carotid artery auscultation

Use the bell, ask the patient to hold their breath, listen for bruits

major arteries supplying the arms

brachial, radial, ulnar arteries

major arteries supplying the legs

femoral, popliteal, posterior tibial, dorsalis pedis arteries

best location for dorsalis pedis pulse

lateral to the extensor tendon of the great toe

abnormal capillary refill response

delayed refill >3sec. may indicate poor perfusion or shock

what is a bruit

turbulent blood flow, often due to arterial narrowing

edema classifications

1+ mild, slight indention

2+ moderate, indentation subsides quickly

3+ deep, indentation remains for a short time

4+ very deep, indentation lasts a long time

causes for weak or bounding pulses

weak 1+ shock, arterial disease

bounding 3+, 4+ fever, anemia, hyperthyroidism

valves producing S1/S2

S1- closure of av valves (mitral (bicuspid), tricuspid)

S2- closure of SL valves (aortic, pulmonic)

AV (atrioventricular)

SL (semilunar)

mitral (left), tricuspid (right)

aortic (left), pulmonic (right)

skin characteristics of venous disease

Warm, swollen, brown discoloration, thickened skin

doppler sounds

Swishing sound indicating arterial or venous blood flow

risk factors for venous ulcers

Varicose veins, prolonged standing, DVT history

best location for posterior tibial pulse

Behind the medial malleolus

assessing lower extremities

Inspect for color, temperature, edema, ulcers, capillary refill, pulses

causes of decreased lower extremity pulses

Atherosclerosis, PAD, embolism, hypovolemia

murmur

abnormal heart sound due to turbulent blood flow

precordium

area overlying the heart and great vessels

dysthymia

abnormal heart rhythm

hypercapnia

increased CO2 in the blood

hyperventilation

increased rate and depth of breathing

hypoventilation

decreased respiratory rate and depth

hypoxemia

low oxygen in the blood

hypoxia

inadequate oxygen at the tissue level

peau d’ orange

orange peel appearance of breast skin

scoliosis

lateral curvature of the spine

kyphosis

hunchback curvature

pectus excavatum

sunken chest

pectus carinatum

pigeon chest

atelectasis

collapsed alveoli

ischemia

reduced blood supply

fremitus

vibration felt on chest wall during speech

mastitis

breast infection

gynecomastia

male breast enlargement

intermittent claudication

pain in legs due to poor circulation

lift/thrill

precordial movement/palpable murmur

cyanosis

bluish skin from hypoxia

bronchophony

increased vocal resonance over lung consolidation

bruit

turbulent blood flow sound

bradypnea

slow breathing

tachypnea

rapid breathing