Breast Examination

Yvette Ethel Mondano-Yap, MD, FPCP, DPSN

The Thorax and the Lungs
Yvette Ethel Mondano-Yap, MD, FPCP, DPSN

Chest Examination consists of inspection palpation percussion and auscultation

Chest Examination
Inspection process initiates and continues throughout the patient encounter. Palpation, confirmed by percussion, assesses for tenderness and degree of chest expansion. Auscultation, a more sensitive process, confirms earlier findings and may help to identify specific pathologic processes not previously recognized.

Locating Findings on the Chest
Chest abnormalities maybe described in 2 dimensions: 1. along the vertical axis 2. around the circumference of the chest To make vertical locations, count the ribs and the interspaces. The sternal angle (angle of Louis) is the best guide.
Note: The costal cartilages of the first 7 ribs articulate with the sternum; the 8th, 9th and 10th ribs articulate with cartilages just above them and the 11th and 12th ribs are floating ribs.

Vertical locations…
… Use the 12th rib posteriorly as another starting point. … Use the inferior tip of the scapula – it usually lies at the level of the 7th rib or insterspace … Use the most protruding spinous process of the vertebrae when the neck is flexed forward – usually the vertebra of C7.

Around the circumference of the chest
- Use a series of vertical lines: midsternal and vertebral midclavicular line anterior and posterior axillary lines midaxillary line scapula line

Locations on the Chest
• • • • • • Supraclavicular – above the clavicles Infraclavicular - below the clavicles Insterscapular - between the scapulae Infrascapular - below the scapula Bases of the lungs – the lowermost portion Upper, middle and lower lung fields

Lungs, Fissures and Lobes

Lungs, Fissures and Lobes
Each lung is attached by its root and pulmonary ligament to the heart and trachea but is otherwise free in the thoracic cavity. Each lung has an apex, three surfaces (costal, medial, and diaphragmatic), and three borders (anterior, inferior, and posterior). The portion of the upper lobe of the left lung that lies between the cardiac notch and the oblique fissure is known as the lingula, and it corresponds to the middle lobe of the right lung. In men, the right lung weighs approx. 625 g, the left 570 g. The lungs contain 300,000,000 alveoli and their respiratory surface is about 70 sq m. Respirations per minute are 12 to 20 in an adult.

The Trachea and the Airways
• The left lung is longer, narrower, and has a smaller volume than the right lung. • The bronchi themselves divide many times before branching into smaller airways called bronchioles. • At the end of each bronchiole are thousands of small air sacs called alveoli. • Within the alveolar walls is a dense network of tiny blood vessels called capillaries.

The Pleurae
… is a thin, glistening, slippery serous membrane, inflammation of which is called pleurisy. … lines the thoracic wall and diaphragm, where it is known as the parietal pleura. It is reflected onto the lung, where it is called the visceral pleura. … the pleural space/cavity is the potential space between visceral and parietal pleurae.

Blood supply, lymphatic drainage and innervation
• The lungs are innervated by parasympathetic fibers via the vagus nerve and sympathetic fibers from the anterior and posterior pulmonary plexuses to the smooth muscle in the walls of the bronchial tree. • The bronchial arteries and veins circulate blood to the bronchial tree. The pulmonary arteries and veins circulate the blood involved in gas exchange. • Superficial and deep lymphatic vessels drain toward the hilus and end in pulmonary and bronchopulmonary nodes. These in turn drain into the tracheobronchial nodes.

The Thorax and the Lungs
Yvette Ethel Mondano-Yap, MD, FPCP, DPSN

Breathing
A. Establishment of Basic Pattern: regulated by neuronal mechanisms 1. Medullary Structures
a. Dorsal Respiratory Group - (Inspiratory Center) b. Ventral Respiratory Group - (Expiratory Center)

2. Pontine Structures
a. Pneumotaxic Center: A role in respiratory patterns b. Apneustic Center: to amplify inhalation – Breathe in deeply and get little expiration of gas – Expiration is impeded but inspiration is not – It amplifies inspiration

Breathing

Quiet Breathing:
Inspiration. The diaphragm is the predominant muscle of respiration. Others involved are parasternals and scalenes Expiration is predominantly a passive phenomenon.

Breathing
During exercise and in certain diseases:
Inspiration:
1. I

and out, increasing the lateral and AP dimensions of the thorax.
2. Scalene

External intercostals raise the lower ribs up muscles and sternomastoids

serving to raise and push out the upper ribs and the sternum.

Active expiration:
1.

abdominus, internal and external obliques, and transversus abdominus), which drive intraabdominal pressure up when they contract. 2. Internal intercostals assist with active
expiration by pulling the ribs down and in, thus decreasing thoracic volume.

Abdominal wall muscles (including the rectus

Respiratory Membrane
• a. Type I: Most of the alveolus cells and are the basic s structural cells • b. Type II: Produces pulmonary surfactant • c. macrophages

Pulmonary Surfactant

- a complex substance containing phospholipids and a number of apoproteins - produced by the Type II alveolar cells - is differentially reduces surface tension, more at lower volumes and less at higher volumes, leading to alveolar stability and reducing the likelihood of alveolar collapse

Changes With Aging
Capacity to exercise decreases Chest wall becomes stiffer and harder to move Respiratory muscles weaken Lungs’ elastic recoil decreases Speed of breathing gradually decreases Skeletal changes e.g. kyphosis and barrel chest

The Thorax and the Lungs
Yvette Ethel Mondano-Yap, MD, FPCP, DPSN

Common or Concerning Symptoms 1. Chest pain
Sources: 2. Myocardium 3. Pericardium 4. Aorta 5. Trachea and large bronchi 6. Parietal pleura 7. Chest wall, including musculosketal system and skin 8. Esophagus 9. Extrathoracic structures such as neck, GB, stomach

Common or Concerning Symptoms
2. Dyspnea nonpainful but uncomfortable awareness of breathing that is inappropriate to the level of exertion. Ask PQRST. 3. Wheezing - musical respiratory sounds

4. Cough -

5. Blood-streaked sputum – coughing up blood
from the lungs

reflex response. Ask if with sputum, volom, color, odor and consistency.

Health Promotion And Counselling
Tobacco cessation Four “As”:
3. 4. 5. 6. Ask about smoking at each visit. Advise patients regularly to stop smoking in clear personalized message. Assist patients to set stop dates and provide educational materials for self-help. Arrange for follow-up visits to monitor and support progress.

Techniques of Examination:
With patient sitting, examine the posterior thorax and lungs with the arms folded across the chest with hands resting on the opposite shoulders. With patient supine, examine the anterior thorax and lungs. For patients unable to sit up without aid, ask help. If not, roll the patient to 1 side and then to the other. - PROCCED in an orderly fashion- IPaPA

History
• • • • • • Pre-existing conditions Family Health History Immunizations status Allergies Current Therapies tried Last Medications

Assessment

80% is Visualization

• Inspection
• • • • • • • • • • • • • • • • Color Level of Consciousness Respiratory RateSymmetry of Chest Quality of Respirations Respiratory Patterns age appropriate Work of breathing Chest Wall Deformities

respiratory patterns
• Bradypnea - abnormally slow respirations • Hyperpnea – deep respirations • Tachypnea - abnormally fast respirations • Apnea - the cessation of breathing resulting from lack of respiratory effort • Kussmaul Breathing - increased rate, deep respiration usually associated with metabolic acidosis • Cheyne Stokes - Respiratory rate and volume progressively increase until they reach a climax, then they cease entirely for 10-50 sec. • Obstructive-Mild to Severe

chest wall deformities
• • Pectus excavatum (funnel chest,

abnormally depressed) • • Pectus carinatum (pigeon chest, abnormal prominence of the sternum) • • Thoracic kyphoscoliosis (hump back) • • Barrel Chest (CF, COPD)

• Palpation:
In health, the chest and lung transmit a vibration, called fremitus, during speech. Fremitus abnormalities may be felt in chronic obstructive lung diseases or obesity, in which the vibration is diminished, and in pneumonia, in which it is increased over the infected lobe.

Palpation Findings • Palpation for nodules and observed abnormalities Soft/Hard/Neurofibromatoses Sinus tracts Costochondral junction Chest pain Symmetry Synchrony Expansion

• Palpation for tenderness:

• Position of trachea • Assess ventilatory excursion:

• Tactile Fremitus
• •

Assess observed abnormalities: Gynecomastia Spider hemangiomas Examine the Lymph Nodes e.g Axillary, Supraclavicular, Cervical LN

• Palpate the Trachea
-

to locate the trachea and verify that it is in the midline. may be displaced by masses in the neck. the trachea gives an indication of the position of the mediastinum within the chest

The best way is to place the index and the middle fingers either side of the trachea and judge whether the distances between it and the sternocleidomastoids are equal on both sides.

• Chest Expansion tests

- to test if both sides of the chest move equally with respiration.

Best technique is to hook your fingers as far around the chest as possible and bring the thumbs together, but they should not be parallel with each other. The thumbs should be off the chest wall and, thus, free to move. Ask the patient to breath in, and watch your thumbs as they move apart. Look for the symmetry of motion between the two sides. Mediastinal Displacement Away from lesion: . Pneumothorax Large Pleural Effusion Towards Lesion: Collapsed Lung. Localised Fibrosis

• Tactile Fremitus
• Ask the patient to say "ninety-nine" several times in a normal voice. ++ • Palpate using the ball of your hand. • You should feel the vibrations transmitted through the airways to the lung.

Tactile Fremitus • Increased fremitus indicates fluid in the
lung or consolidation of the underlying lung tissue.

• Decreased fremitus indicates sound

transmission obstructed by chronic obstructive pulmonary disease (COPD) fluid outside the lung (pleural effusion) air outside the lung (pneumothorax)

• Palpate the Lymph nodes.
The idea is to feel all the 'walls' of the axilla: the superior, medial, lateral and posterior. Use your left hand to palpate the patient's right axilla and use your right hand to palpate the patient's left axilla. It should be noted that lung disease rarely involves the Axillary lymph nodes. Also palpate the supraclavicular and cervical LN

The purpose of percussion in the respiratory examination is to detect whether the underlying lung tissues are air filled, fluid filled, or solid.

• Percussion: Tapping on the chest wall over healthy lung results in a hollow resonant sound.

• • • • •

STEPS Hyperextend the middle finger of the left hand. This finger is known as the pleximeter finger. Place it on the chest, running in the space between two adjacent ribs. It is important that the pleximeter finger is placed flat against the chest wall. Separate the fingers as wide as possible and make sure the thumb, the index, ring and little fingers are not touching the chest. The right middle finger (the plexor finger) is used to strike the pleximeter finger. It is important that the tip of the plexor finger (and not the finger pad) is used to strike the DIP joint of the pleximeter finger. Following the strike, the plexor finger should be removed as quickly as possible to avoid damping the vibrations.

• The chest should be percussed in 5 areas on each side, again comparing the right and left sides at each step. • It is usual to strike the pleximeter finger 2 or 3 times in quick succession before pausing to move on the next area.

• Posterior Chest
• • • • • • •

Percuss from side to side and top to bottom using the pattern shown in the illustration. Omit the areas covered by the scapulae. Compare one side to the other looking for asymmetry. Note the location and quality of the percussion sounds you hear. Find the level of the diaphragmatic dullness on both sides. Diaphragmatic Excursion Find the level of the diaphragmatic dullness on both sides. Ask the patient to inspire deeply. The level of dullness (diaphragmatic excursion) should go down 35cm symmetrically

• Percussion Findings
Abnormal lungs may be: hyperresonant, dull, or stony dull. Dullness is expected over the liver and over the heart. Obese patients may show reduced resonance, but this is equal on both sides. Percussion Notes and Their Meaning
Intensity Pitch Duration
short medium long longer -

Location
thigh liver

Flat

soft high e.g. Large Pleural Effusion Dull medium medium e.g. Lobar Pneumonia Resonance loud low e.g. Healthy Lung or Bronchitis Hyperresonant VL lower e.g. Emphysema, Pneumothorax Tympany loud high e.g. Large pneumothorax

normal lung gastric bubble

• Auscultation
• most important examining technique to assess airflow through the tracheobronchial tree • it helps to assess the condition of the surrounding lungs and pleural space.

Auscultation involves
• • • Listening to the sounds generated by breathing Listening for any adventitious (added) sounds If abnormalities are suspected, listening to the sounds of the patient’s spoken or whispered voice as they are transmitted through the chest wall (transmitted voice sounds)

Procedure
• Start with listening to the apices of the lung. Then listen over the chest using the diaphragm, and then listen to the lateral part of chest. You should listen in 5 areas on each side of the chest, comparing right and left sides at each step. • Identify patterns of breath sounds by their intensity, their pitch and the relative duration of their inspiratory and expiratory phases.

Breath sounds • produced by vibrations due to turbulent airflow through out the airways. These sounds are transmitted through the smaller airways and lungs to the chest wall. • the intensity of the sounds increase during inspiration and then fade away during the first third of expiration.

Breath Sounds
• Vesicular Breath Sounds - These are soft and low-pitched sounds that are heard over most of the lungs. They are heard through inspiration and continue without pause through to expiration, but fade away about one third of the way through expiration. Bronchovesicular Breath Sounds - These are slightly louder and of higher pitch than vesicular sounds. The inspiratory and expiratory sounds are about equal in length. They may be head normally in the 1st and 2nd interspaces and between the scapulae. Bronchial Breath Sounds - These are loud and high-pitched sounds, whose expiratory phase lasts longer that the inspiratory phase. Heard over the manubrium, if heard at all. Also result from enhanced transmission of higher frequency sounds through solid lung tissue as in consolidation or fibrosis. Tracheal sounds – very loud, harsh sounds, inspiratory and expiratory sounds are about equal, heard over the trachea in the neck.

Notes on Breath Sounds…
• If bronchovesicular or bronchial sounds are heard distant from those listed, then you should suspect that air-filled lung has been replaced by fluidfilled or solid lung tissue. • Breath sounds may be decreased when airflow is decreased (as by obstructive lung disease or muscular weakness) or when transmission of sound is poor ( as in pleural effusion, pneumothorax or emphysema). • A silent gap between inspiratory and expiratory sounds suggests bronchial breath sounds.

Adventitious (Added) sounds Discontinuous Sounds (Crackles/Rales/Crepitations)
Fine crackles occur in inspiration and are soft, high-pitched, brief sounds (5-10msec). - be imitated by rubbing some hair between your fingers near your ear. - occur due to the 'popping' opening of small airways that were closed prematurely at the end of the previous expiration. Coarse crackles are somewhat louder, lower in pitch and not quite so brief (20-30msec) - occur when there is fluid in the larger bronchi. •  

Crackles…
Listen for the following characteristics: Loudness, pitch and duration Number ( few to many) Timing in the respiratory cycle Location in the chest wall Persistence of their pattern from breath to breath • Any change after a cough or a change in patient’s position • • • • • •

Crackles
May be due to abnormalities of the lungs or of the airways. If they occur early on in inspiration reflect bronchiectasis or chronic bronchitis. If they occur later in inspiration, then they may be due to restrictive conditions of the lungs such as pneumonia, fibrosis or pulmonary edema. • Typically if it is associated with Pulmonary Oedema and Fibrosing Alveolitis affect both lung bases equally, whereas in pneumonia and in mild bronchiectasis the crackles are localised. Bear in mind that normal individuals may have a few basal crackles after maximal expiration. Can also be heard in dependent portions of the lungs after prolonged recumbency. These often clear on coughing. Early inspiratory crackles are heard most often in chronic bronchitis and emphysema, are fairly coarse, and change with coughing.

Adventitious sounds
Continuous Sounds longer than crackles (>250msec), musical Wheezes – high-pitched, with hissing or shrill quality - predominantly expiratory sounds that reflect localised narrowing of the airways. Asthma and Chronic bronchitis are the most common causes. Occasionally, they may occur with pulmonary oedema. Stridor is an inspiratory wheeze associated with upper airway obstruction (croup) caused by a foreign body or possibly a tumour. Rhonchi - relatively low-pitched, ften have a "snoring" or "gurgling" quality. Any extra sound that is not a crackle or a wheeze is probably a rhonchi which suggests secretions in large airways.

Adventitious sounds
• Pleural Rub – - squeaky to- and fro-rubbing sound - occurs when inflamed surfaces of the pleura rub together. Causes include pleurisy (a virus or bacterium infects the pleurae), pneumonia and pulmonary embolism, etc. They usually occur in inspiration and in expiration.

• VOCAL RESONANCE
Auscultation of the chest while the patient speaks can provide extra information about the patient’s lungs. Ask the patient to say "99" every time you change your stethoscope position over the patients chest wall. Vocal resonance is increased over solid areas of lung with open airways - for example, consolidation; and decreased by pleural fluid. This part of the physical exam has largely been replaced by the chest x-ray.

Voice Transmission Tests • Bronchophony Ask the patient to say "ninety-nine" several times in a normal voice. Auscultate several symmetrical areas over each lung. The sounds you hear should be muffled and indistinct. Louder, clearer sounds are called bronchophony. Whispered Pectoriloquy Ask the patient to whisper "ninety-nine" several times. Auscultate several symmetrical areas over each lung. You should hear only faint sounds or nothing at all. If you hear the sounds clearly this is referred to as whispered pectoriloquy. Egophony Ask the patient to say "ee" continuously. Auscultate several symmetrical areas over each lung. You should hear a muffled "ee" sound. If you hear an "ay" sound this is referred to as "E -> A" or egophony.

• Peripheral Cyanosis This is where the peripheries, such as the fingertips, adopt a bluish tinge, and occurs due to reduced circulation to the limbs. The peripheries are also usually cold. This may be due to: . Cold weather. Raynaud's Phenomenon. Peripheral Vascular Disease. May also occur in Heart Failure, when there is reduced perfusion to the extremities • Central Cyanosis The most common causes: . Severe Airflow Limitation. Pulmonary Fibrosis. Left Ventricular Failure • Look inside the mouth for evidence of central cyanosis. Ask the patient to open their mouth as wide as possible, and stick their tongue up to the roof of their mouth. Look at the under-surface of the tongue for any bluish tinge, which will signal central cyanosis.

Look for Clubbing. This is where there is an increase in the soft tissues of the nail bed and fingertip. There are many ways to detect clubbing, each looking for its different stages. It recommended that, in OSCE's, all of these be done, to make it obvious that you looking for clubbing. Causes of Clubbing Rock the Nail from side to side on the nail bed. This will detect any bogginess (softening of the nail bed), which is the first stage of clubbing. Squat down beside the bed, so that you are looking side-on at the finger, and your eyes are level with the nail. This allows you to look at the angle between the nail and the nail bed (the nail-bed angle). This is normally concave, and about 160o. But, if the fingers are clubbed, it may be obliterated i.e. flat (180o) or even convex. Look for the Diamond Sign. Ask the patient to place their index fingers together, with their nails facing each other and touching. Normally, the concave nail-bed angle on each finger will create a 'diamond' area in between the fingers. This will be obliterated in clubbing

• •

• • • • • • • • • • • • • •

Causes of Clubbing enlarge Respiratory . Bronchial Carcinoma (most common) . Pleural / Mediastinal tumours, e.g. Mesothelioma . Chronic Suppurative Lung Disease e.g. CF, Bronchiectasis, Abscesses . Lung Fibrosis Cardiac . Congenital Cyanotic Heart Disease e.g. Fallot's Tetralogy . Subacute Infective Endocarditis Gastrointestinal . Cirrhosis . IBD . Coeliac Disease

• Look for Tar Staining, which indicates that the patient is a smoker. Smoking is an important risk factor for bronchial carcinoma and COPD, as well as other nonrespiratory conditions

• Ask the patient to hold out their arms in front of themselves, parallel to the bed, with the wrists extended fully (i.e. the palms should face forward). Ask them to close their eyes, and hold that pose for about 10 seconds. If they have any Carbon dioxide retention (or, indeed, if they have liver disease) a tremor will be elicited. This is known as CO2 Flap and is indistinguishable from Liver Flap.

Chronic Bronchitis
Process -Excessive mucus production in bronchi, followed by chronic obstruction of airways

Chronic Bronchitis
Timing -Chronic productive cough followed by slowly progressive dyspnea Factors that Aggrevate -Exertion, inhaled irritants, respiratory infections

Chronic Bronchitis
Factors that Relieve -Expectoration; rest, though dyspnea may become persistent Associated Symptoms -Chronic productive cough, recurrent respiratory infections; wheezing may develop

Chronic Bronchitis
Setting -History of smoking, air pollutants, recurrent respiratory infections

Chronic Bronchitis
Physical Exam: Inspection -patient complains of symptoms for more than 2-6 months -patient has labored breathing -may use 2nd accessory respiratory muscles -cough is deep seated with elevation of shoulders; sputum is mucoid to purulent , may be blood streaked or even bloody -patient looks fine, doesn’t look ill at all

Chronic Bronchitis
Palpation -equal vocal fremitus, slightly louder on the right -course rhonchi -both bases disappear after coughing and expelling sputum

Chronic Bronchitis
Percussion -mild-no change, percussion notes are resonant, loud in intensity, low in pitch, long in duration as seen in a normal lung Auscultation -moist rales over lung bases that do not clear on coughing

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