PA exam #2

Anterior Thoracic Cage

Suprasternal notch, Sternum, manubriosternal angle (angle of louis), costal angle

Posterior Thoracic Cage

Vertebra Prominens (C7), Spinous Processes, Inferior border of the scapula (7th or 8th rib), 12th rib (palpate midway between spine and side to find the location free tip_

Reference Lines (anterior + posterior)

Anterior Axillary Line, Midclavicular line, midsternal line, scapular line, vertebral line

Lateral Reference Lines

anterior axillary, posterior axillary, midaxillary lines

Structure of Lungs

Pleurae (visceral, parietal), Costodiaphragmatic recess, trachea, bronchial tree

Mechanics of Ventilation

supply O2 to body for energy production, remove CO2 as a waste product, maintain acid-base balances of arterial blood, maintain heart exchange

Thoracic Past Medical History (PMH)

ask patient about…

• existing respiratory diagnosis

• allergies

• lung injury

• history of intubation

• smoking

• respiratory exposure

• previous thoracic surgeries

• lung disease/cancer in family

Thoracic Review of Systems (ROS)

Frequent respiratory infections, cough, sputum production (hemoptysis = blood-streaked sputum), dyspnea (SOB), dyspnea on exertion, wheezing, orthopnea, chest pain with breathing

Trauma Informed Care

realizing the widespread impacts of trauma, recognizing signs and symptoms of trauma, responding by fully integrating knowledge about trauma into policies, procedures and practices, seeking to actively resist re-traumatization

Thoracic Physical Exam Overview

1. Inspection

2. Respiratory excursion

3. Palpate for tactile fremitus

4. Percuss for symmetry

5. Diaphragmatic excursion

6. Auscultate posterior chest

7. Repeat inspection, palpation, percussion and auscultation on anterior chest

Thoracic: Inspection

• observe for signs of respiratory distress

• note skin abnormalities/color

• note shape and configuration of chest wall

• listen for any audible sounds of breathing (wheezing, stridor, whistling)

Tripod Positioning

It's commonly adopted by individuals experiencing shortness of breath or respiratory distress, as it can help improve breathing

Stridor

Abnormal Finding! Medical emergency!

• audible harsh, high pitched, crowing sounds associated with airway obstruction in or near the larynx

• can be heard on inspiration and/or expiration

• May hear with or without a stethoscope

• Medical emergency

• Ex: croup, epiglottitis, foreign body aspiration, airway edema from anaphylaxis

Respiration Patterns

• Normal Breathing,

• Sigh,

• Tachypnea (shallow breathing >20/min),

• Bradypnea (<12/min, with or without a change in tidal volume),

Respiration Patterns Contd.

• Hyperventilation (more than standard tidal volume ex: Kyssmaul breathing)

• Cheyne-Stokes (death and dying breathing pattern with periods of apnea (no breathing) and then kicks in with increased tidal volume and then decreases)

• Ataxic Breathing - Biot’s (brain dead)

• Paradoxical Breathing (brain injury, diaphragm moves in opposite direction than it should during inspiration and expiration causing the lung to deflate during inspiration)

Thoracic Inspection:

AP: Transverse Ratio

• normal anteroposterior:transverse ration = 1:2

• Costal angle should be around 90 degrees

Abnormal Configurations of the Thorax

Barrel Chested (COPD), Pectus excavatum, Pectus Carinatum, Kyphoscoliosis, Kyphosis,

Barrel Chested

abnormal, COPD

Pectus Excavatum

abnormal, more dangerous because the sternum is tucked in and there’s pressure on the underlying organs

Pectus Carinatum

abnormal

Kyphoscoliosis

abnormal, ribs closer together on one side and ribs rather apart on other

Kyphosis

abnormal, common in post-menopausal women with osteoporosis

Infant Thorax

Developmental Considerations! Barrel Chest in infant is normal!

Palpate for symmetric Chest Expansion

• Place both hands on posterior chest with thumbs at T9 or T10

• Pinch up a small fold of skin

• Ask person to take a deep breath

• Thumbs should move apart symmetrically

• HOT TIP: T7 is in line with the inferior tip of scapula

• Normal finding: symmetrical expansion of the chest

Palpate for tactile fremitus

• Use palmar base of fingers or ulnar edge, touch chest while patient says “ninety-nine”

• Start over apices and palpate from side to side to make a comparison

• Normal finding: symmetrical vibrations

• HOT TIP: the vibrations of sounds are conducted BETTER through a DENSE OR SOLID structure than a porous one so anything that increases density of lung will increase fremitus

  • Hear it louder over tumor

  • Air = porous

Thoracic: Percussion - Good Technique

• ask the patient to cross their arms to spread the back

• hyperextend your middle finger and press distal interphalangeal joint firmly in the intercostal space

• Ideally no other finger will touch the chest wall (will dampen sound)

• Use tip of your opposite middle finger to strike the distal joint with firm and quick strokes

• Use the lightest pressure that produces a clear note and increase striking power if needed for a thicker chest wall

• Start at the apices and move from side to side for comparison as you move downward to about T10

Percussion of the posterior Chest

percussion helps to establish whether the underlying tissues are air-filled, fluid-filled, or consolidated

Consolidation: when the air that usually fills the small airways in your lungs is replaced with pus, blood, water or a solid)

General Principles for Percussion Notes

• Percussion produces sound that reflects the density of the underlying structure

• Structures with more internal air (lungs) produce a louder, deeper and longer percussion notes because the sound can vibrate more freely

• A denser, more solid structure (liver) gives a softer highter, shorter percussion not because the internal fluid/dense tissue restricts sounds from vibrating as freely

• The depth of percussion has limits: vibrations produced from percussion only reaches a depth of about 5cms

Percussion Notes

• Flat

• Dull

• Tympany

• Resonance

• Hyperesonance

Flat

• more dense/solid tissue

• Very soft, high pitched, short duration

• Heard over very dense tissue (bone or muscle)

Dull

• More dense/solid tissue

• soft, muffled, moderate to high pitched, short duration

• normal finding over dense fluid filled tissue such as the liver

• If heard over the lung field, may indicate lobar pneumonia

Tympany

• loud, drum like, high pitched or musical sounds, moderately long duration

• Normal heard over enclosed air/fluid filled cavities (ex: stomach, bowel, bladder)

• If heard in lung may be large pneumothorax

Resonance

• Less dense/more air tissue

• Moderate to loud, low pitched (clear hollow), moderate duration

• Normally heard over air filled tissues (healthy lung tissue)

Hyperresonance

• less dense/more air tissue

• loud booming, very low pitched, long duration,

• hyperinflated lungs as with COPD (overfilled balloon)

Expected Percussion Notes on Posterior Chest

Diaphragmatic Excursion

Diaphragmatic Excursing is the descent of the diaphragm with respirations

• percuss for diaphragmatic excursion

• assess degree of symmetry for diaphragm movement with respiration

• Normal excursion = 3-5.5cms and symmetrical bilaterally

• HOT TIP: you aren’t percussing the actual diaphragm, but rather the boundary between the resonant lung tissue and the duller structures below

• Absent decent of the diaphragm can indicate pleural effusion or atelectasis of lower lobe on the affected side

Auscultate Posterior Lung Fields

• Listen in a similar pattern as percussion for side to side comparison while the patient takes deep breaths

• Use the DIAPHRAGM and hold firmly against bare skin

• Listen in each location for one full respiration starting at the apices (C7) to the bases (T10), as well as laterally from axilla down to 8th/9th rib

• Healthy lungs will be clear to auscultation (CTA)

Normal Breath Sounds by Location

• Bronchial (tracheal) = loud, course, blowing sound, normal over trachea, length of inspiration heard < or = expiration

• Bronchovesicular = medium pitched, moderately loud, normal over mainstem bronchi, length of inspiration heard = expiration

  • NOT normal to hear bronchovesicular in the peripheral lung field

• Vesicular = soft/low pitched breezy sound, normal over peripheral lung fields, length of inspiration is heard > expiration

General Principles of Breath Sound Volume

• Normal, air-filled lungs are insulators of sound coming from within (voice/breath sounds)

• Vocal sounds from within the lung travel more easily through liquid (or densities) compared to air, therefore breath sounds are louder over areas of consolidation in the lung.

• Breath sounds are quieter than normal over areas where fluid or air has accumulated within the pleural space because there is a physical barrier preventing the sound from making it to your stethoscope.

• When there is an airway blockage (food, mucous plug, etc), you will note diminished or absent breath sounds in areas distal to that blockage due to the prevention of air flow to those airways.

Adventitious Breath Sounds

Abnormal!

• Fine Crackles (like hair twisting)

  • crackling or popping, commonly heard on late inspiration

  • caused by air colliding with secretions or small airways popping open

• Course Crackles (like velcro)

  • harsh, moist popping/bubbling sounds heard on early inspiration

  • caused by air bubbles moving through secretions in the large bronchi

Adventitious Breath Sounds Contd.

Abnormal!

Wheezes

• Sonorous (Ronchi)

  • low pitched snoring sounds most heard on expiration

  • Single note like musical snoring or moaning

  • Caused by blockages in the main airways by secretions, foreign body or a mass (ex: bronchitis)

• Sibilant

  • squeaky sound heard during inspiration and expiration

  • caused by narrowed/blocked airways as with asthma attack

Pleural Friction Rub

• Grating sound heard during inspiration and expiration

• Occurs when the pleura become inflamed and rub together

• Ex: Pleurisy, pneumonia, pulmonary embolism lung cancer

Transmitted Voice Sounds

• Only do test if there’s abnormal bronchovesicular or bronchial breath sounds

• Assess the transmitted voice sounds using on of these techniques (indicative of underlying consolidation if present)

  • Bronchophony

  • Egophony

  • Whispered Pectoriloquy

Bronchophony

• listen while the patient ways “99”

• NORMALLY sounds are muffled/indistinct

• IF BRONCHOPHONY IS PRESENT, sounds will be louder/clear, indicating abnormality like pneumonia

Egophony

• Listen while the patient says “EE”

• NORMALLY will hear a muffled long E sound

• IF EGOPHONY IS PRESENT, the E will sound like an A and may indicate pneumonia

Whispered Pectoriloquy

• Listen while patient whispers “99”

• NORMALLY faint/absent sound

• IF WHISPERED PECTORILOQUY, louder clear whispered “99”

Inspection: Anterior Chest Wall

• shape and configuration of chest wall (not deformities or asymmetry)

• accessory muscles (not any retractions)

Palpate for Symmetric Anterior Chest Expansion

Palpate for Tactile Fremitus

• may use ball of palm or the ulnar surface of the hand

• If breasts are present, gently displace the tissue to assess beneath as necessary

• Normal finding: equal bilaterally

Percuss the anterior Chest

Auscultate Anterior Chest

• RML is auscultated best on the anterior chest

Summary of Healthy Lung Exam Findings

• Trachea = midline

• Tactile Fremitus = normal/symmetrical

• Percussion = resonant

• Breath Sounds = vesicular except over large bronchi or trachea

• Adventitious Sounds = none

• Tracheobronchial tree and alveoli are clear, pleurae are thin and close together, mobility of chest wall is unimpaired

Atelectasis

Partial Lobar Obstruction, Abnormal! Collapse of the alveoli due to mucous plug, foreign body or due to surrounding pressure

• trachea = may be shifted towards involved side in SEVERE situations

• tactile fremitus = decreased to absent over the affected area

• percussion = dull over collapsed airless area only

• breath sounds = decreased or absent over collapsed airless airleas

• adventitious sounds = may have wheezes (rhonchi) and crackles depending on severity

Consolidation

Lobar Pneumonia, Abnormal! Infection causing the alveoli to fill with fluid, bacteria, blood and pus

• Trachea = midline

• Tactile Fremitus = increased over involved are with bronchophony

• Percussion = dull over involved are

• Breath Sounds = bronchial over involved area (should be vesicular)

• Adventitious sounds = crackles over involved area

• may be accompanied by fever

Pneumonia

fluid in alveoli and inflamed bronchiole

Bronchitis

inflammation of the bronchi (usually chronically), causing mucous build up

• trachea = midline

• tactile fremitus = normal

• percussion = resonant

• breath sounds = vesicular except perhaps over large bronchi or trachea

• Adventitious sounds = non OR course crackles and/or sonorous wheezes (rhonchi)

Emphysema

slowly progressive disorder (often due to smoking) in which the distal air spaces enlarge, and lungs become hyperinflated; often also develops chronic bronchitis

• trachea = midline

• tactile fremitus = decreased

• percussion = hyper-resonant

• breath sounds = decreased to absent

• adventitious sounds = none or scattered coarse crackles and/or sonorous wheezes (rhonchi) associated with chronic bronchitis

• Over time will develop barrel chest, severe DOE, and decreased diaphragmatic excursion

• COPD

• exhalation is the problem, still left over air that’s trapped, so over time it increases!

Asthma

widespread, usually intermittent and reversible narrowing of the tracheobronchial tree (bronchospasm and underlying inflammation), diminishing airflow

• trachea = midline

• tactile fremitus = decreased during attacks

• percussion = resonant to hyper-resonant during attacks

• breath sounds = often obscuring by wheezes during/surrounding attacks

• adventitious sounds = wheezes during attacks

Pleural Effusion

fluid accumulation in the pleural space, separating air-filled lung from the chest wall, blocking the transmission of sound

• trachea = shifted toward unaffected side with severe, large effusions only

• tactile fremitus = decreased to absent over affected area

• percussion = dull over fluid/affected area

• breath sounds = decreased to absent over affected area

• adventitious sounds = usually none, however friction rub possible over affected area

• can be result of “third spacing”, pneumonia, cancer, etc

Pneumothorax

air leak into the pleural space, usually unilaterally, causing the lung to recoil from the chest wall. Pocket of air in the pleural space blocks the transmission of sound via stethoscope

• trachea = shifted away from the involved side if excessive (tension pneumothorax)

• tactile fremitus = decreased to absent over affected area

• percussion = hyper-resonant over affected area

• breath sounds = decreased to absent over affected area

• adventitious sounds = none

• usually accompanied by SOB/DOE and low O2 saturation

• air leak into that airspace

Types of pneumothorax

• closed pneumothorax = least severity, pleural cavity pressure is < the atmospheric pressure

  • ex: collapsed lung, scuba diving, blunt trauma, smoking/inhaled drugs, various lung diseases

• open pneumothorax = middle severity, pleural cavity pressure is equal to atmospheric pressure

  • traumatic pneumo, blunt or penetrating injury, invasive medical procedures

• tension pneumothorax = most severity, pleural cavity pressure is > the atmospheric pressure

  • trauma causing one way valve

Pulmonary Edema (Congestive Heart Failure)

increased pressure in pulmonary vasculature due to fluid overload, causing congestion and interstitial edema around the alveoli and fluid may push into alveoli. Bronchial mucosa may also be edematous

• trachea = midline

• tactile fremitus = normal to decreased

• percussion = resonant

• breath sounds = vesicular

• adventitious sounds = crackles in the dependent portions of lungs, possibly wheezes - fluid alveolar sacks with water

• may be accompanies by JVD, lower extremity edema, hepatomegaly, DOE

Pulmonary Embolism

blockage in the arteries bringing blood to the lung tissue (usually a clot), which leads to lung tissue damage

• trachea = midline

• tactile fremitus = normal

• percussion = resonant

• breath sounds = vesicular

• adventitous sounds = usually none

• may be accompanied by SOE/DOE, tachycardia, pain with inspiration, cardiac arrest

External anatomy of assigned female at birth (AFAB) Mammary Gland

• The AFAB mammary tissue lies between 2nd and 6th ribs, between the sternal edge to mid axillary line.

• The nipple is just below center

• The superior lateral corner called Tail of Spence projects up and into axilla.

• Developed mammary tissue is composed of

  • glandular tissue which is located into 15-20 lobes surrounding the nipple

  • fibrous bands of tissue including suspensory ligaments (Cooper’s), which support the glandular tissue

  • fat or adipose tissue throughout and predominates the mammary tissue

Clinical Points of References for breasts

Clock and Quadrants

• upper inner quadrant

• upper outer quadrant

• lower inner quadrant

• lower outer quadrant

• axillary tail of Spence

Lymphatics of breast

Axillary nodes

• central axillary nodes

• pectoral nodes

• subscapular nodes

• lateral axillary nodes

Drainage patterns

Supernumerary Breast or Nipple

extra nipples

Tanner Stages

• Stage 1: pre adolescent - elevation of nipple only

• Stage 2: breast bud stage - elevation of breast and nipple as a small mound; enlargement of areolar diameter

• Stage 3: further enlargement of elevation of breast and areola

• Stage 4: projection of areola and nipple to form a secondary mound above the level of breast/chest

• Stage 5: mature stage, projection of nipple only. Areola has receded to general contour of the breast/chest

AMAB Mammary Tissue

• Rudimentary structure consisting of a thing disk of undeveloped tissue underlying the nipple

• Areola is well developed, although the nipple is relatively very small

• During adolescence, it is common for the breast tissue to temporarily enlarge, producing gynecomastia - usually unilateral and temporal

• Gynecomastia (abnormally enlarged AMAB mammary tissue) may appear with aging due to testosterone deficiency

• Most breast cancers in AMAB patient appear under the nipple

Breast PMH

• personal history of breast disease/cancer

• surgeries

• family history of breast cancer

• self-care behaviors

Breast ROS

• pain

• lump

• nipple discharge

• skin changes/rash

• swelling

• trauma

• nippel inversion

Preparation for breast exam

• position

• draping (gown should be open in front, drape the side not being examined)

• Small pillow

• Ruler marked in centimeters or caliber

Inspect

• Note size and symmetry (mild baseline asymmetry can be normal)

• Note contour (masses, dimpling, flattening)

• Note skin color, thickening, edema, venous pattern

• Visible blue vascular pattern over bilateral breasts is normal finding during pregnancy. Unilateral, pronounced vasculature (esp in the absence of pregnancy) is abnormal

Inspect: Retraction Maneuvers

tissue should move symmetrically and hang freely without pulling, dimpling or retractions

• patient bends down

Edema (Peu d’orange)

abnormal

• can be a sign of inflammatory breast cancer

• radiation can cause this as well, ask history

Retractions/Dimpling

abnormal

• dimpling

• retractions

• these are both breast cancers and tumors

Inspection of Nipple

• Note size, shape, direction in which they point (inversion present)

  • ask if inversion has always been like that

• Note rashes, flaking, fissures or ulcerations

• Note any obvious spontaneous discharge (is it clear, milky, purulent, blood)

  • if it’s unilateral and bloody, that’s a concern

  • bilateral clear or milky discharge can be normal

Possible Nipple Findings

• Nipple retraction (can be normal OR abnormal)

• Paget’s Disease (abnormal)

  • covered in eczema/scales

Inspect and Palpate Axillae

• Note rash or skin changes signifying infection

• Lift pts arm and support it yourself (use left hand to palpate right axilla)

• Reach high into axilla and palpate in 4 directions

  • down mid axillary line, anterior axillary line, posterior axillary line, along inner aspect of upper arm

• Note any palpable lymph nodes

  • tenderness?

  • ALWAYS investigate palpable lymph nodes!

Palpate Breasts

• Best position is when tissue is flattened

• A thorough exam should take 3 min/side

• Use fingertips with light, medium and deep pressure

• Bimanual palpation is helpful with large pendulous breast tissue

Pattern of Breast Palpation

• Spokes on a wheel

• Vertical strips

• Wedges

• Concentric circles

Breast Bimanual Palpation

• specially helpful with large pendulous mammary tissue

• also helpful to further characterize a lump if not felt well in the supine position

If any lumps are present, note:

• Location - clock or quadrants (more specific the better)

• Size - width x length x depth

• Shape - oval, round, lobulated

• Consistency - soft, firm, hard

• Mobility - movable, fixed

• Distinctness - solitary or multiple

• Nipple - displaced or retraction

• Overlying skin - erythema, dimpling, retraction

• Tenderness

• Lymphadenopathy

Palpate Nipple

• if discharge is present, note color, quantity, and consistency

• keep hands flat and down and inward

Discuss Breast/Chest Self Awareness

• Recommendation of:

  • national comprehensive cancer network (NCCN)

• Understand/Learn what your “normal” is so abnormalities can be detected

• Changes to look for

  • a lump

  • nipple discharge other than milk, especially a bloody discharge

  • swelling

  • a range in size or shape

  • skin irritation, such as redness, thickening or dimpling of the skin

  • swollen lymph nodes in the armpit

  • nipple problems, such as pain or redness

Assessment of assigned male at birth (AMAB) mammary tissue

• DO NOT OMIT (everyone gets a chest exam)

• Inspect the chest wall noting skin surface and any lumps or swelling

• Palpate the nipple - should feel even with no nodules

• Typically has a flat disk of undeveloped tissue beneath the nipple

• Gynecomastia = feels like a smooth firm/rubbery, movable disk beneath the nipple (unintentional swelling of the breast tissue)

  • occurs normally during puberty and may be unilateral or bilateral

  • can also occur in the aging population due to drops in testosterone

• Most cancers will appear beneath or immediately around the nipple in biological males

Fibroadenomas

• benign finding

• most commonly aged 15-25, but up to age 55

• usually single, may be multiple

• round, disclike, or lobular

• may be soft, usually firm

• well delineated

• very mobile

• usually nontender (some patients say it’s tender)

Fibrocystic Breast Disease

• most common benign finding

• thickening of generalized tissue with cyst formation (may be intermittent)

• Age 30-50, regress after menopause except with estrogen therapy

• Most common benign breast condition

• Cysts are round, well delineated, soft to firm, and elastic feeling/bouncy

• Cysts are mobile and often tender

• On exam, overall nodular/dense feel

• very painful before period

Mammary Carcinoma

AFAB:

• most common over 50, however can be diagnosed at a very young age

• most common area is upper outer quadrant

AMAB:

• most common >60 years old

• Most often found beneath or just around the nipple

Both:

• usually single, although may coexist with other nodules

• irregular or stellate

• firm or hard

• not clearly delineated form surrounding tissues

• may be fixed to skin or underlying tissues

• usually nontender

• may have associative lymphadenopathy

• if no lymph nodes involved then it’s not metastatic

Possible signs of breast cancer

• retracted or inverted nipple

• breast or nipple pain

• lumps

• nipple discharge

• swelling

• redness/rash

• charges to skin texture

• lump around collar bone or underarm

AFAB cancer risk factors

Non modifiable risk factors:

• Cisgender female > 50

• Personal history of breast cancer

• Mutation of BRCA I and BRCA 2 (among others)

• First-degree relative with breast cancer

• Previous breast/chest irradiation

• Menarche < 12; menopause > 50

Modifiable risk factors:

• Nulliparity or first child after 30

• Use of combined HRT (esp in post menopausal setting)

• Alcohol intake of 2+ drinks daily (but really any amount)

• Physical inactivity

• Post menopausal obesity

• Never breast/chest feeding

AMAB cancer risk factors

• age > 60

• Family History of breast cancer

• BRCA I or 2 mutation

• Exposure to estrogen

  • hormone therapy for prostate cancer

  • gender affirming hormone therapy including estrogen/progesterone

• Klinefelter’s syndrome

• liver disease

• obesity

• disease/surgery of testicles

Pulmonary/Systemic Circulation

Internal Position/Surface Landmarks

• precordium

• mediastinum

• 2nd to 5th intercostal

• Base vs apex

• Apical impulse/PMI

Great Vessels of the Heart

Neck Vessels

Layers of the heart

Internal Anatomy of Heart

Heart as a pump

systole: SI - closing of AV valves - the ventricles contract

• the right ventricle pumps blood into the pulmonary arteries (pulmonic valve is open)

• the left ventricle pumps blood into the aorta (aortic valve is open)

diastole: S2 - closing of semilunar valves - the ventricles

• blood flows from the right atrium → right ventricle (tricuspid valve is open)

• blood flows from the left atrium → left ventricle (mitral valve is open)