Physical Assessment: Breasts, Cardiovascular, Respiratory, and Peripheral Vascular Systems

Comprehensive practice flashcards reviewing anatomy, physical assessment techniques, normal findings, and pathological conditions of the breast, axilla, cardiovascular, respiratory, and peripheral vascular systems.

Between which anatomical landmarks on the anterior chest wall do the adult female breasts typically lie?

The breasts lie anterior to the pectoralis major and serratus anterior muscles, located between the $2\text{nd}$ and $6\text{th}$ ribs, and extending from the sternal edge to the midaxillary line.

What is the axillary tail of Spence?

The superior lateral corner of breast tissue that projects cone-shaped upward and laterally into the axilla, lying close to the pectoral group of axillary lymph nodes.

What are Montgomery glands, and what is their physiological function?

Small elevated sebaceous glands situated in the areola that secrete a protective lipid material during lactation.

What are the suspensory ligaments of Cooper, and what clinical sign occurs when an invasive neoplasm infiltrates them?

Fibrous connective tissue bands extending vertically from the skin surface to chest wall muscles to support breast tissue; growing neoplasms cause fibrosis that contracts these ligaments, creating skin dimpling (skin tethering).

What proportion of breast lymph drains into the ipsilateral axillary lymph nodes, and which four node groups make up this basin?

More than $75\%$ drains into the ipsilateral axillary nodes, which include: (1) central axillary, (2) pectoral (anterior), (3) subscapular (posterior), and (4) lateral.

What congenital anatomical variant along the embryonic milk line is depicted here?

A supernumerary nipple, which represents an extra nipple and areola persisting along the embryonic mammary ridge (milk line), usually located $5\text{ to }6\,\text{cm}$ below the breast near the midline.

What are the physical characteristics of the five Tanner stages of female adolescent breast development?

Stage $1$ (Preadolescent): Small elevated nipple only; Stage $2$ (Breast bud): Small mound of breast and nipple develops, areola widens; Stage $3$: Breast and areola enlarge with nipple flush; Stage $4$: Areola and nipple form a secondary mound; Stage $5$ (Mature breast): Only the nipple protrudes, with the areola flush with the breast contour.

How do colostrum and mature breast milk differ in timing of expression and nutritional composition?

Colostrum can be expressed after the $4\text{th}$ month of pregnancy and the first few days postpartum; it is a thick, yellow fluid rich in antibodies, protein, and lactose, but containing practically no fat. Mature milk production begins $1\text{ to }3\text{ days}$ after delivery and appears whitish due to emulsified fat and calcium caseinate.

Which risk factors confer a relative risk greater than $4.0$ ($>4.0$) for invasive breast cancer in women?

Age (adults $\ge 65\text{ years}$ versus $<65\text{ years}$), biopsy-confirmed atypical hyperplasia, lobular carcinoma in situ (LCIS), and pathogenic genetic mutations (such as BRCA1, BRCA2, PALB2, or TP53).

Which physical maneuvers contract the pectoralis major muscle to screen for hidden breast dimpling or retraction?

Asking the patient to push her hands firmly onto her hips or push her palms together.

How do fibroadenomas clinically differ from invasive breast carcinomas on palpation?

A fibroadenoma is a benign, nontender, solid, rubbery, well-circumscribed, and freely movable mass common in late adolescence and young adulthood. Invasive carcinoma is typically a solitary, unilateral, stony-hard, fixed mass with irregular, poorly delineated borders.

What are the characteristic clinical findings and nursing management for acute lactation mastitis?

Presents as a red, swollen, tender, hot, and hard inflammatory mass in one breast quadrant, accompanied by flu-like symptoms (fever, chills, headache, tachycardia); management includes rest, local heat, antibiotics, and frequent nursing or pumping to maintain complete emptying without weaning.

What is the normal anatomical location and dimensions of the adult apical impulse?

Located at the $4\text{th}\text{ or }5\text{th}$ intercostal space at or medial to the left midclavicular line ($7\text{ to }9\,\text{cm}$ from the midsternal line), normally measuring $1 \times 2\,\text{cm}$ as a short, gentle tap occupying the first half of systole.

What physiological events generate the first ($\text{S}_1$) and second ($\text{S}_2$) heart sounds?

$\text{S}_1$ is produced by the closure of the atrioventricular (AV) valves (mitral and tricuspid), signaling the beginning of systole. $\text{S}_2$ is produced by the closure of the semilunar valves (aortic and pulmonic), signaling the end of systole.

Why does physiological splitting of the second heart sound ($\text{S}_2$) occur on inspiration?

Decreased intrathoracic pressure on inspiration increases venous return to the right heart, which increases right ventricular stroke volume, prolongs right ventricular systole, and delays pulmonic valve closure ($\text{P}_2$); concurrently, temporary pulmonary pooling lowers left heart return, allowing aortic closure ($\text{A}_2$) to happen slightly earlier ('MoRe to the Right, Less to the Left').

What mechanism produces the third heart sound ($\text{S}_3$, ventricular gallop), and when is it considered pathologic?

Vibrations produced during early diastole (protodiastole) by rapid blood filling into a stiff or volume-overloaded ventricle; it is normal in children and young adults but is always pathologic in adults over $35\text{ years}$ of age, often representing the earliest physical sign of heart failure.

What produces a fourth heart sound ($\text{S}_4$, atrial gallop), and when does it occur in the cardiac cycle?

It occurs late in diastole (presystole), immediately before $\text{S}_1$, when atria contract and force blood into a noncompliant, stiff ventricle (such as with hypertension, CAD, aortic stenosis, or cardiomyopathy).

In this anatomical diagram of the heart and great vessels, what are the superior and inferolateral boundaries called?

The broad superior aspect where the great vessels lie is the base, and the pointed inferolateral tip that directs downward and to the left is the apex.

What are the five traditional precordial auscultation locations for heart valve sounds?

Aortic area ($2\text{nd}$ right intercostal space), Pulmonic area ($2\text{nd}$ left intercostal space), Erb's point ($3\text{rd}$ left intercostal space), Tricuspid area (left lower sternal border, $4\text{th}\text{ or }5\text{th}$ intercostal space), and Mitral area ($5\text{th}$ intercostal space at the left midclavicular line).

What technique should the examiner employ when auscultating the carotid arteries for bruits?

Lightly apply the bell of the stethoscope over the artery at three levels (angle of the jaw, midcervical area, and base of the neck), instructing the patient to inhale, exhale, and briefly hold their breath on expiration to silence tracheal breath sounds.

How is jugular venous pressure (JVP) measured, and what cutoff signifies elevated central venous pressure?

With the patient elevated at a $30\text{ to }45\text{-degree}$ angle, measure the vertical height from the sternal angle (angle of Louis) to the highest point of pulsation; a pulsation level greater than $3\,\text{cm}$ above the sternal angle at $45\text{ degrees}$ is elevated.

What are the four cardiac defects that characterize Tetralogy of Fallot?

(1) Pulmonic (right ventricular outflow) stenosis, (2) ventricular septal defect (VSD), (3) compensatory right ventricular hypertrophy, and (4) an overriding aorta.

How does dynamic postural change (standing to squatting) distinguish the systolic murmur of hypertrophic cardiomyopathy (HCM)?

The systolic murmur of HCM grows softer with standing-to-squatting (increased venous return) and grows louder with squatting-to-standing (decreased venous return).

Why is the sternal angle (angle of Louis) an essential thoracic landmark?

It marks the articulation between the manubrium and body of the sternum, is continuous with the $2\text{nd}$ rib, overlies the tracheal bifurcation (carina), marks the superior border of the cardiac atria, and corresponds to the $4\text{th}$ thoracic vertebra posteriorly.

How do the lobar configurations of the right and left lungs differ, and which lobes occupy the posterior chest wall?

The right lung has $3$ lobes (upper, middle, lower) separated by horizontal and oblique fissures, while the left lung has only $2$ lobes (upper and lower); the posterior chest consists almost entirely of the lower lobes.

What is the normal ratio of anteroposterior (AP) to transverse chest diameter, and what defines a 'barrel chest'?

The normal ratio is $0.70\text{ to }0.75$ (or $1:2$); a barrel chest features an equal $1:1$ AP-to-transverse diameter with horizontal ribs and a costal angle $>90^\circ$, caused by lung hyperinflation in chronic emphysema or COPD.

What clinical condition causes increased tactile fremitus, and why does this occur?

Lobar pneumonia (consolidation); dense lung tissue acts as a superior acoustic conducting medium for vocal sound vibrations, provided the connecting bronchus remains patent and consolidation reaches the lung surface.

What respiratory physical exam technique is depicted in this figure, and at what vertebral level is it performed?

Palpation of symmetric chest (thoracic) expansion, evaluated by placing warmed hands posterolaterally with thumbs pinched together at the level of $T9\text{ or }T10$.

What are the pitch, duration, and anatomical locations of the three normal adult breath sounds?

Bronchial (tracheal): High pitch, loud, inspiration $<$ expiration, heard over trachea and larynx; Bronchovesicular: Moderate pitch, moderate amplitude, inspiration $=$ expiration, heard over major bronchi (upper sternum and between scapulae); Vesicular: Low pitch, soft rustling, inspiration $>$ expiration, heard over peripheral lung fields.

What physical mechanism distinguishes crackles from wheezes?

Crackles (discontinuous) result from inhaled air colliding with deflated airways or secretions, popping open collapsed air sacs; wheezes (continuous) result from air squeezed through narrowed or compressed tracheobronchial passages.

What finding constitutes an abnormal egophony test, and what pathology does it signify?

The auscultated spoken 'eeee' sound transforms into a high-pitched, bleating nasal 'aaaaa' sound (voice of a goat) over areas of pulmonary consolidation or compression.

What forced expiratory time and $\text{FEV}_1/\text{FVC}$ ratio suggest airflow obstruction?

A forced expiratory time of $\ge 6\text{ seconds}$ (normal is $\le 4\text{ seconds}$) and an $\text{FEV}_1/\text{FVC}$ ratio of less than $70\%$ (normal is $\ge 75\%$).

What three physiological mechanisms return venous blood back to the heart?

(1) Skeletal muscle contractions (the calf pump or 'peripheral heart'), (2) thoracic and abdominal pressure gradients generated during respiration (thoracic pressure drops while abdominal pressure rises during inspiration), and (3) intraluminal one-way pocket valves.

Which specific body regions drain into the right lymphatic duct versus the thoracic duct?

The right lymphatic duct empties into the right subclavian vein, draining the right side of the head, neck, right arm, right thorax, right lung, right heart, and right upper liver. The thoracic duct drains the entire remainder of the body into the left subclavian vein.

Where is the epitrochlear lymph node palpated, and which areas does it drain?

Palpated in the antecubital fossa in the groove $2\text{ to }3\,\text{cm}$ above and behind the medial condyle of the humerus; it drains lymph from the hand and lower forearm.

What clinical procedure is illustrated in this diagram, and what constitutes a normal response?

The modified Allen test, which evaluates collateral circulation via the ulnar artery before radial artery cannulation; a normal result is a palmar blush returning in less than $7\text{ seconds}$.

How do chronic arterial symptoms (PAD) differ from chronic venous symptoms in pain character and aggravating factors?

Arterial pain (intermittent claudication) presents as a deep muscle ache or cramp brought on by walking a fixed claudication distance and relieved by rest or dangling. Venous pain presents as a diffuse aching, heaviness, or tiredness in the lower leg that worsens at the end of the day or after prolonged standing/sitting, and is relieved by leg elevation and walking.

What distinguishing objective ulcer characteristics differentiate arterial from venous leg ulcers?

Arterial ulcers occur on tips of toes, metatarsal heads, and lateral malleoli, presenting with dry, pale, punched-out edges and absent bleeding. Venous ulcers occur over the medial malleolus, presenting with irregular shallow borders, active granulation tissue, weeping exudate, and surrounding brown hemosiderin staining.

What is the formula for calculating the Ankle-Brachial Index (ABI), and what value confirms peripheral artery disease (PAD)?

Right (or Left) ABI equals Highest ankle pressure (DP or PT) on that side divided by the Highest arm pressure (right or left); an ABI of $\le 0.90$ indicates PAD.

What are the three factors that comprise Virchow's triad for venous thrombosis?

(1) Venous stasis, (2) hypercoagulability, and (3) endothelial damage or vein wall trauma.

What are the three progressive color phases seen in the digits during a Raynaud phenomenon episode?

(1) White (pallor) from sympathetic vasoconstriction, (2) blue (cyanosis) from capillary blood pooling and deoxygenation, and (3) red (rubor) from reactive hyperemia after rewarming.

What Wells score threshold indicates a high clinical pretest probability for deep vein thrombosis (DVT)?

A score of $3\text{ points or higher}$ ($\ge 3$) on the Wells clinical prediction model.