1
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
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Cough
 Productive vs Non-productive (sputum production)
 Hemoptysis (coughing up blood)
Dyspnea (SOB)
 Wheezing
 Cyanosis
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Chest Pain
Stridor (noisy breathing)
Voice changes (vocal cords)
Swelling of ankles (dependent edema)
Sleep Apnea
Relevant History
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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
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Hobbies (exposure to resp. irritants)
Use of alcohol
Use of illegal drugs
Exercise tolerance
Immunizations (TB)
Current chest x-rays
Respiratory System Risk Factors
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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
-dental problems are the most common cause of lung abscesses
Extreme obesity
-warm humidity helps to open airways and stop coughing, and then
Difficulty swallowing
cold air helps to sooth tissues
Weakened chest muscles
-in early stage CHF, people cough lightly when in the supine
Hx. of frequent respiratory infections
position
Severe cardiovascular disease
Coughing
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Onset
Palliative/Provocative
Quality (Nature of cough)
Severity
Pattern
Associated Symptoms
Treatment (type, effect)
Descriptors of Coughing
(table 13-1)
 Dry, hacking (virus, allergy)
 Chronic (bronchiectasis)
 productive
 Wheezing (asthma, allergy, CHF)
 Barking (croup – epiglottal dx)
 Stridor (tracheal obstruction)
Appearance of Sputum (table 13-2)
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Mucoid (asthma, TB, emphysema)
Mucopurulent (asthma, TB, emphysema)
Yellow-green/ purulent (bronchiectasis)
Rust-colored/ Purulent (pneumococcal pneumonia)
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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
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Hemoptysis (table 13-3)
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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
-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)
1/14/07
Dyspnea (SOB) (table 13-8)
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Dyspnea on Exertion (DOE)
Onset (when, mode, progression)
Palliative
Provocative (exertional, positional)
Pattern
Associated symptoms
Associated conditions
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Grading 1-5 (1st establish a baseline)
 1- Excessive activity
 2- Moderate activity
 3- Mild activity
 4- Minimal activity (ie dressing oneself)
 5- Rest
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)
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Pneumonia
Pneumothorax
Pulmonary Constriction
Peanut (or inhaled foreign object)
Pulmonary Embolus
Pericardial Tamponade
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Pump Failure (CHF)
Peak seekers (high altitudes)
Psychogenic (anxiety)
Poisons
Wheezing & Noisy Breathing
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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
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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)
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**Positional Dyspnea (page 369) – table 13-4
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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)
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Central – cardiorespiratory pblm
 Dec. O2 in lungs
 Severe C/R ds.
 Lips, oral mucosa, nail beds
 Gets worse with warming of body
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Peripheral – venous stasis
 Venous Stasis
 Exposure to cold
 Nail beds, nose, lips
 Cyanosis decreases with warming
Chest Pain
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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
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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
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Peripheral Assessment
Inspection of Chest & Thorax
Palpation
Percussion
Auscultation
Peripheral Signs
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Posture
Facial Expression
Use of Accessory Respiration Muscles
Clubbing of Nails (pg 376)
Cyanosis (central)
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*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
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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)
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
Ds. of Chest Expansion/Lag
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Chronic fibrotic disease (lung or pleura)
Pleural effusion
Pneumothorax
Lobar pneumonia
Pleural Pain (splinting)
Unilateral bronchial obstruction
Palpation of the Chest/Thorax
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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
5
-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
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)
Ds. Of Chest expansion/Lab (B/L)
-chronic fibrotic disease (lung/pleura) – B/L
-obesity
-COPD
-Ascites – organomegaly
-Diaphragmatic disease
Respiration - rate, rhythm, depth
Ds. of Chest Expansion/Lag (U/L)
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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
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: <10 bpm (well-conditioned athlete)
-incr intracranial pressure (headache), neoplasia,
aneurysm, head trauma (subdural hematoma)
Tachypnea: >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
Chest Expansion
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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)
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
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*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
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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
7
*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
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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
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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)
*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
Diaphragmatic Excursion
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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
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Breath Sounds (type, intensity)
Adventitious Sounds
Vocal Resonance
 Bronchophony
 Egophony
 Whispered Pectoriloquy
Breath Sounds
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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)
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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
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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)
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Decrease:
 COPD
 Chest wall weak
 Pleural effusion
 Pneumothorax
 Bronchial Obstruction
 Thickened Wall
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
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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
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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
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*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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11
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********
-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
General Questions
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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)
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Location
Onset (When, How, Change)
Does it change with menses?
Pain (tenderness) Pattern
Skin Lesions, Color variations
Nipple Change
Symptoms/Complaints
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Mass or Swelling
Pain
Nipple Discharge/Deviation
Change in Skin over Breast
Breast Pain
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Location: Unilateral/Bilateral
Any Trauma
OPPQRST
Change In Bra Size
Pattern
Associated Symptoms
12
Nipple Change
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Discharge
Depression or inversion
-Could be a tumor pulling nipple in
-not problematic if nipples have always been inverted
Deviation
Discoloration
Dermatologic changes
Nipple Discharge
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Location: Unilateral/Bilateral
Onset
Describe Change/Discharge
Related to Menses
Medications/Oral Contraceptives
Associated Symptoms
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
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Change in Color or Texture
 Edema
 Dimpling, puckering, retraction
 Discoloration
 Rash
Breast Exam Procedures
-Inspection
-Palpation
-Axillary lymph node evaluation
Inspection: Breast Tissue
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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
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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
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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
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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
13
Nipple & Areola Examination
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Inspection: 5 D’s
Palpation: note thickening, pain
Gently compress or strip nipple
Note any discharge
Evaluate Axillary Nodes
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Inspection
 Lesions: rashes, masses
 Discoloration (unusual pigmentation)
Palpation
 Location
 Number
 Discrete/Matted
 Size
 Tenderness
 Mobility
Inspection: Nipples
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Size, shape, symmetry
Discharge
Depression or inversion
Deviation
Discoloration
Dermatologic changes
Table 16.2
-most malignancies occur in the upper
outer quadrant
Lymph Node Assessment
Enlarged axillary nodes from infection, recent immunization, neoplasia, or generalized – check epitrochlear
…
Screening Guidelines (NCI)
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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
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~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