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8/11/2019 Chest and Lungs 2012
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byG,
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loyd,
Ni-ne
andChocoBoots
CLINICAL MEDICINE - 1
T H O R A X A N D L U N G SDr. Susan Lee (September 2012)
Trans by: BabyG, Jam Lloyd, Ni-ne and Choco Boots
CHEST AND LUNGS
Patients Complaint:
Cough most common symptom
Dyspnea
Chest pain
Sputum production (with/without hemoptysis)
Hoarseness problem in larynx
Snoring
Altered mental function due to very severe lung problem (CO2 and O2)
can also be due to metabolic problem (blood sugar or
blood sugar)Past Medical History
Work History
Lifestyle
Travel
COUGH
Forceful projection of air under pressure from the trachea-bronchial tree and alveoli
MECHANISMS:
VOLUNTARY REFLEX
Afferent Limbsensory distribution of CN V, IX, superior laryngeal and X
Efferentrecurrent laryngeal nerve (glottic closure, spinal nerves
(contraction of thoracic nerves and abdominal diaphragm)
COUGH
Stimulus initiates deep inspiration
Glottis closure
Relaxation of diaphragm
Muscle contraction against closed glottis
Increased intra-thoracic pressure
Sudden opening of the glottis
Sudden release of pressure plus
Tracheal narrowing
Very fast airflow
(air close to speed of sound)
Forces mucus out of airway
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ETIOLOGY:
Inflammationpneumonia
Mechanical irritationinhalation of dust particles
Decrease pulmonary compliance- heart failure; pleural effusion lungs hard
to expand exert more effort
Chemical Thermalhot air; cold air
Primary complexpneumonic infiltrates; large lymph nodes in mediastinum
area in heart cause pressure and tension in trachea and R and L bronchus
COMPLICATION:
Cough Syncope: increase intra-thoracic pressure increase VR to heart
decrease cardiac output decrease perfusion to the brain
Rupture of Emphysematous Bleb pneumothorax
Rib fracture
Costochondritis
ONSET
ACUTE ONSET lasts for < 3weeks; associated with lung airway or lung
parenchyma
Laryngitis
Tracheatis
Bronchitis
Bronchiolitis
Acute pulmonary edema
URTI
Pneumonia Asthma
Pleural effusion
CHRONIC ONSET lasts for > 3 weeks
PTB
COPD
Lung tumor
Bronchiectasis
Fungal infection
Mediastinal mass
Interstitial lung disease
Chronic rhinitis/sinusitis
GI problem
CV disease
CHARACTER
Brassy Cough trachea or L/R main stem bronchus
Barky Cough epiglottis
Purulent sputum yellowish/very viscous
Mucoid whitish; less dense/viscous consistency
Foul-smelling infectionanaerobes microorganisms
Purulent Sputum (ACUTE) lung abscess
(CHRONIC) bronchiectasis
>2 months
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CAUSE
CAUSE CHARACTERISTIC
ACUTE INFECTIONS OF LUNG
Laryngitis Dry cough (without sputum), may
become productive of variable amountsof sputum; An acute, fairly minor illness
with hoarseness. Often associated with
viral nasopharyngitis
Tracheobronchitis Cough associated with sore throat, runny
nose and sore eyes
Lobar Pneumonia Cough often preceded by symptoms of
URTI; Cough is dry, painful at first, then
becomes productive fever, simple
chills
Bronchopneumonia Cough dry or productive; usually beginsas acute bronchitis
Mycoplasma/Viral Pneumonia Paroxysmal cough, productive of mucoid
or blood-stained sputum associated with
flu-like symptoms; generalized body
malaise, myalgia (joint pains)
Exacerbation of Chronic Bronchitis Cough mucoid or purulent sputum
FOREIGN BODY
Immediate while still in upper airway Cough associated with progressive
evidence of asphyxiation
Later when lodged in lower airway Non-productive, persistent, associated
with localized wheezes
CARDIOVASCULAR
Pulmonary Infarction (sub-condition of
pulmonary embolism)
Cough associated with hemoptysis,
usually with pleural effusion
LV Failure Cough intensifies while in supine
positionalong with aggravating of
dyspnea
Pulmonary Emboli Dry to productive; may be dark, bright
red, or mixed with blood; Dyspnea,
anxiety, chest pain, fever; factors that
predispose to deep venous thrombosis
CHRONIC INFLAMMATION
Postnasal Drip Chronic cough; sputum mucoid or
mucopurulent; Repeated attempts to
clear the throat. Postnasal discharge may
be sensed by patient or seen in posterior
pharynx. Associated with chronic rhinitis,
with or without sinusitis
Chronic Bronchitis Chronic cough; sputum mucoid to
purulent, may be blood-streaked or even
bloody; Often long-standing cigarettesmoking. Recurrent superimposed
infections. Wheezing and dyspnea may
develop.
Bronchiectasis Chronic cough; sputum purulent, often
copious and foul-smelling; may be blood-
streaked or bloody; Recurrent
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bronchopulmonary infections common;
sinusitis may coexist.
Pulmonary Tuberculosis Cough dry or sputum that is mucoid or
purulent; may be blood-streaked or
bloody; Early, no symptoms. Later,
anorexia, weight loss, fatigue, fever, andnight sweats
Lung Abscess Sputum purulent and foul-smelling; may
be bloody; A febrile illness. Often poor
dental hygiene and a prior episode of
impaired consciousness
Gastroesophageal Reflux Chronic cough, especially at night or early
in the morning; Wheezing, especially at
night (often mistaken for asthma), early
morning hoarseness, and repeated
attempts to clear the throat. Often ahistory of heartburn and regurgitation
PARENCHYMAL INFLAMMATORY PROCESSES
Interstitial Fibrosis Cough, non-productive, persistent,
difficulty of breathing
Smoking Cough usually associated with reddish
reddish, infected phranyx; most marked
in the morning
TUMORS
Bronchogenic CA Cough, non-productive to productive for
weeksto months, recurrent small
hemoptysis
Alveolar Cell CA Cough similar to bronchogenic CA except
in instances when large quantity of
watery mucoid sputum
Benign Cough, non-productive; associated with
hemoptysis
Mediastinal Breathlessness, caused by compression
of lungs
Aortic aneurysm Brassy cough
DYSPNEA
Sensation experienced by the patient when act of breathing becomes uncomfortable,
distressing, difficult and labored
Trepopneadifficulty of breathing in lateral decubitus position
Platypneadifficulty of breathing on upright position
Orthopneadifficulty of breathing on supine position; suggestive of heart failure
ACUTE DYSPNEA
1. Asthma
2.
Acute pulmonary edemaa. Narcotic overdose
b. altitude
c. Neurogenic
3. Pneumothorax
4. Pneumonia
5. Acute pulmonary embolism
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6. Chest injury
7. ARDS
8. Pleural effusion
9. Pulmonary hemorrhage
ASTHMA because of allergic condition, hyperresponsive airwayDOB
SPONTANEOUS PHEUMOTHORAX can be primary or secondary; acute onset;
preceded by pleauritic pain(very sharp); precipitated by valsalva maneuver(pain)
PULMONARY EMBOLISM Significant risk factor is deep vein thrombosisprolonged
immobilization (plus oral contraceptive)
ANXIETY WITH HYPERVENTILATION increase rate of breathing; decrease PaCO2
alkalosis; some patiets tetany
CHRONIC PROGRESSIVE DYSPNEA Symptoms develop gradually
1. COPD
Eg. Emphysemaover distension of air spaces distal to terminal
bronchiole
More of dyspnea rather than cough
2. Asthma
3. Pleural effusion
4. Psychogenic
5. Tracheal stenosis
6. Hypersensitivity disorder
7.
Left ventricular failure8. Diffuse interstitial fibrosis
9. Pulmonary thromboembolism
10.Anemia, severedue to severe chronice blood loss such as in colonic CA
11.Pulmonary vascular diseaseobstructed pulmonary vasculature pulmonary
hypertension
AMERICAN THORACIC SOCIETY DYSPNEA SCALE
GRADE DEGREE
Not troubled by SOB when hurrying on the level or walking
up a slight of hill
0 None
Troubled by SOB when hurrying oon the level or walking up
on slight hill1 Mild
Walks more slowly than people of the same age on the
level because of breathlessness or has to stop for breath
when walking at own pace of level
2 Moderate
Stop for breath after walkimg about 100 yarsd or after a
few min on level3 Severe
Too breathless to exert breath or dressing or undressing4
Very
severe
HEMOPTYSIS
Coughing up blood
RESPIRATORY GASTROINTESTINAL
bright red Brownish/dark red
Admixed with sputum Admixed with food
Alkalotic Acidic
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ORIGIN
Upper respiratory tract
Lower respiratory tract
QUANTITY Massive emergency; patiemt can die due to asphyxiation; blood will clot;
800-100ml of blood /24 hours
CAUSES
Inflammatory
Bronchiectasis
Bronchitis
PTB
Lung abscess
Pneumonia
Neoplasm
Lung CA
Bronchial adenoma
Others
Pulmonary emboli
Left sided failure
Hemorrhagic diatheses
Primary pulmonary HPN
AV malformation
Ersenmenger syndrome
Pulmonary vasculitis
AIRWAYS
Bronchitis
Bronchiectasis
Cystic fibrosis
Neoplasm
Parenchyma
Localized
o Pneumonia
o
Lung abscesso Tuberculosis
o Aspergillosis
o Bronchitis
o Cystic fibrosis
Diffuse
o Goodpasture syndrome
o Idiopathic pulmonary hemosiderosis
Vascular
o Pulmonary emboli
o AV malformation
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CHEST PAIN
- Ask about PQRST of the pain (Quality, Severity, Frequency, Associated symptoms,
Ameliorating factors, and Exacerbating circumstances)
- Cardiovascular problem: either angina pectoris or MI
- Angina: the severity of pain is less than MI, mild to moderate pain; usually last for only
10-20mins. The problem is the obstruction of the coronary arteries due to sclerosis. This
is usually felt at the retrosternal area and sometimes radiate to left upper extremities.
The pain is usually described as squeezing, heaviness, precipitated by effort, emotional
stress, heavy meal or exposure to cold and relieved by rest. The patient usually presents
nausea, excessive sweating or DOB.
In MI:the pain would be very very severe, lasting for >20min.
- Pericarditis: pain is usually described as sharp or knife-like that radiates to the tip of the
shoulder, aggravated by change in position, coughing, and swallowing.
- Dissecting aneurysm: depends on the location of tear. Aorta is divided into 2 lumen:
true and false lumen. Tear is usually in the tunica intima that goes into the t. media and
cause a false lumen. Then the aorta becomes a two-tube lumen. Risk factor is HPN. The
pain is described as very very sharp, located at anterior or posterior chest wall.
- Respiratory: tracheatis or pleuritic chest pain.
- Tracheatis: felt in the retrosternal area and usually described as a burning sensation.
Aggravated by coughing or deep breathing and relieved by rest.
-
Pleuritic chest pain: very sharp pain due to inflammation of the pleura which is maybean extension from the lung infection or primary pleural infection (pleuritis). Generally
located in the anterolateral portion of the chest wall. Aggravated by deep breathing and
coughing, relieved by lying down on both sides.
- GI problem: Gastroesophageal reflux: pain at the retrosternal area, described as
squeezing or burning sensation. Aggravated by large meal, lying down, relieved by
intake of antacid, associated by dysphagia.
- Diffuse esophageal spasm: similar to the pain of MI or angina. Located at the
retrosternal area and may radiate to the back and to the arm. Usually described assqueezing. Precipitated by food intake and emotional stress.
- Chest wall pain: the only condition associated with chest tenderness. Located in the
costal cartilages, below the breast. Pain is stabbing, dull or aching, sometimes very
severe. Aggravated by chest movement or deep breathing.
-
Anxiety: cause is unclear and variable
- Hoarseness: due to overuse of vocal cords that may lead to nodule formation. Singers
note or teachers note. May precipitate from pts with lung CA that spread to the
mediastinal area.
-
Snoring: due to overwt, structural problem, too tired, too much alcohol that relaxes
striated muscles in the throat that leads to narrowing of oropharyngeal airway.
Develops into sleep apnea.
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Drug toxicity
1. Interstitial infiltrating disease: Bleomycin, Cyclophosphamide, Methotrexate,
Nitrofurantoin
2. Non cardiogenic pulmonary edema: Aspirin
3. Bronchospasm: -blockers, NSAIDS (Ibuprofen, Mefenamic)
4. Pulmonary vasculitis: intravenous drug abuse
5. Pulmonary thromboembolism: oral contraceptives
6. Respiratory muscle weakness: Aminoglycosides antibiotics
Family History
- Cystic disease, pulmonary emphysema secondary to 1 antitrypsin deficiency, cystic
fibrosis
Occupational history
- Asbestos exposure that lead to mesothelioma, coal, silica, beryllium, bogasse, iron oxide
tin oxide, cotton dust, titanium oxide, silver, nitrogen dioxide, animals, airconditioners,
furnace humidifier
Personal and social history
Cigarette smoking Increase risk compared with non smokers
Coronary artery disease 2-3x higher
Stroke 2x higher
Peripheral vascular disease 10x higher
COPD mortality 10x higher
Lung CA mortality 23x higher in men, 13x higher in women
- Histoplasmosis: South and Midwestern US
- Coccidiodomycosis: Southwestern US
- Hydatid cysts: Mediterranean Basin
- Paragonimiasis: Central China: Sorsogon and Basilan
- Shistosomiasis cavity cor pulmonale: Egypt, Samar and Leyte and some parts of
Mindanao
- Bronchospasm: allergy to pets
- Acute pneumonitis: psittacosis, tularemia, Q fever
-
Alcoholics: aspiration pneumonia, pneumococcal pneumonia, Klebsiella pneumonia- IV drug abusers: lung abscess
- Pneumocystis jiroveci
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A N A T O M Y- Sternum, ribs and clavicle
- Sternal angle of Loius = 2nd
ant rib
- 7 pairs of true ribs, 2 pairs of floating ribs, false ribs
-
C7most prominent spinous process- Anterior rib is lower than posterior rib
- Inferior angle of scapula: 8th
rib
- Needle for thoracentesis : space between 7th
and 8th
rib
- Mid-axillary line= apex of axilla; important in insertion of chest tube for diagnostic
procedure
- Apex of lung: exceed ~2-4cm above the clavicle
- Lung (R&L): Major (oblique) fissure: spinous process of T3 -> going laterally to the lateral
chest wall, downward -> up to 5th
rib of mid axillary line -> ends at 6th
rib
- Right lung: Minor (horizontal) fissure: 5th
rib mid axillary line following 4th
anterior rib
- Bifurcation of trachea: posterior=T4 spinous process, anterior=sternal angle
P H Y S I C A L E X A M I N A T I O N O F C H E S T INSPECTION, PALPATION, PERCUSSION, AUSCULTATION
INSPECTION
Face
- color, expression, level of consciousness, nasal flaring (pediatric pts), pursed lip
breathing (emphysema and COPD pts)
Body position
- posture (pts with severe asthma = stooping forward)
- weight
Neck
-
tracheal position from midline
- jugular vein distension (due to increase intrathoracic pressure)
- characteristic tripod sitting position
-
overweight, edematous, bluish discoloration, Blue bloater = chronic bronchitis-
Check for any subcutaneous vessels, nodules, pustules
Chest
- Diameter (Normal A/P = to 1/3 lateral)
- Symmetry: pneumothorax, flail chest (due to multiple rib fracture), splinting (one side is
expanding more than the other)
- Rib angles: 45; (in COPD: more horizontal)
- Deformities: pectus excavatum, scars, lesions, kyphoscoliosis
- Muscular hyperthrophy
-
Barrel chest: A-P diameter, Normal in infancy, seen in COPD patients- Funnel chest: pectus excavatum
- Pigeon chest: pectus carinatum (sternum is depressed anteriorly)
- Thoracic kyphoscoliosis: (vertebral rotation, deform the chest, and distortion of
underlying lungs)
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- Traumatic flail chest: one portion of lung is moving to the opposite direction from the
rest of chest wall due to multiple rib fracture
Breathing pattern
- I/E ratio: 1:2 (I/E ratio: extended exhalation)
-
Excursion: chest vs. abdominal; depth, retractions or bulging; accessory muscle use;
unilateral
- Rate: tachypnea / bradypnea
- Rhythm: Cheyne-Stoke, Kussmauls, Biots
- Seesaw pattern: respiratory muscle fatigue -> respiratory arrest
- Respiratory alternance
- Retractions of suprasternal notchaccessory muscle use
- Look for intercostals spacesbulging (intathoracic P), narrowing
Respiratory rate and rhythm
- Eupnea (normal)
- Tachypnea, apnea, hyperpnea, hypopnea (abnormal RR)
- Cheyne stoke, Biots, Kussmauls, apneustic (abnormal rhythm)
Eupnea
- Normal rate, 12-20bpm
- Normal sighs: 7/hr
Tachypnea
-
rate (>25bpm), regular rhythm- Causes: N during sleep, diabetic pts, coma, metabolic acidosis, brain tumor, ICP,
uremia, drug intake (alcohol, narcotics)
Apnea
- Absence of breathing
- Causes: respiratory or cardiac arrest, ICP
Hyperpnea
- N rate, deep breathing (TV), regular rhythm
- Causes: exercise, fever, pain, respiratory disease
Hypopnea
- N rate, shallow depth, regular rhythm
- Causes: circulatory failure, meningitis, uncal herniation
Cheyne-Stoke respiration
- Periods of predicted apnea
- rate and depth of breathing, then breaths followed by periods of apnea (20-60sec)
- Normal in newborn and aged, CHF, aortic valve lesion, dissecting aneurysm, CO2
sensitivity, meningitis, ICP, cerebral anoxia, drug overdose, renal failure
Kussmauls respiration
- Very fast and deep breathing (>20/min) like sighs with no respiratory pause
- Causes: diabetic ketoacidosis, severe hemorrhage, peritonitis, renal failure, uremia
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Biots breathing
- Similar to Cheyne-Stoke respiration
- Fast and deep breathing, with unpredictable periods of apnea and no set rhythm
- Causes: spiral meningitis, ICP, CNS lesions or disease
Apneustic breathing- Long gasping inspiration with insufficient expiration
- Cause: lesion in pneumotaxic center (pontine problem)
Skin:mucous membrane, color
Fingers:clubbing, tremors
Sputum
Vital signs
Clubbing of digits
Pulmonary and thoracic
Primary lung CaMetastatic lung Ca
Bronchiectasis
Cystic fibrosis
Lung abscess
Neurogenic diaphragmatic tremors
Chronic inflammation (empyema)
Cardiac problem: Congenital Cyanotic Heart Disease, sub-acute bacterial endocarditis
Hemiplegia
PALPATION
a.
Trachea
b. chest excursion
-symmetry/logging
-expansion of chest wall
3 cm long in women
4-6 cm in men
c.
tenderness/fractures
d. skin
-turgor, masses, subcutaneous, emphysemadiaphoresis
e. PMI
-midline structure, NOTE for shifting of PMI
structures like heart
f.
Tactile Fremitus
g. Subcutaneous Emphysema
-collection of air in subcutaneous tissue
-pneumothorax
-chest wall is bulgy (crackling sensation)h. Back
-paravertebral line
-make fold in the midvertebral line
-thumb in midline
i.
Anterior
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-parasternal line
-make fold in midsternal line
-thumb will move away from the midline in equal distance
Conditions that cause LAGGING:
1.
Atelectasis2. Pneumothorax
3. Pleural effusion
4. Pleuritic chest pain
5. Chest wall pain
Feel Fremitus- base of palm side
Decreased Fremitusair, fluid or fibrous barrier
pneumothorax, effusion, pleural thickening, thick chest wall,
decrease airflowairway obstruction
Increase Fremitusconsolidation: atelectasis if there is airway obstruction
pneumonia, infarction and tumor
airway obrstructionatelectasisdecreased fremitus need other factor to increase fremitus
PERCUSSION
-set the chest wall and underlying tissues I motion, producing audible sound and palpable
vibrations
a.
Technique of percussion (right handed)
-Hyperextend the middle finger of left hand (known as thepleximeterfinger). Press its
distal
interphallanged joint firmly on the surface to the percussed.
-flexor and pleximeteruse the index and middle finger
-thumb, 2nd
,4th
, and 5th
fingersnot touching the chest
-Fleximeter placed in intercostal space
-area of auscultation same as area of percussion
b.
Percussion Notes and Their Characteristics
Relative
Intensity
Pitch Duration Ex of
location
Pathological
Example
Flatness Soft Hight Short Thigh Longe?
pleural
effusion
Dullness Medium Medium Medium Liver Lobar
pneumonia
Resonance Loud Low Long Healthy lung Simple chronic
bronchitis
Hyperresonance Very loud Lower Longer Usually none COPD
pneumothorax
Tympany Loud High Gastric car
bubble, or
puff out
chest
Large
pneumothorax
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Flatnessmassive atelectasis, massive pleural effusion, pneumonectomy
Dullnessatelectasis, consolidation neioplasm, fribrosis, pleural effusion, pleural thickening,
pulmo edema enlarged heart
Hyperresonanceemphysema, acute sternal pneumothorax
Tympaniticmassivfe pneumothorax, large pulmonary arteryDullnesslevel of diaphragm
increase diaphragmincrease dullnessproblem
Right Diaphragm- ICC higher
Up to 2 interspace or 5-6 cmdiaphragm can descend
High setting of diaphragmdiaphragmatic paralysis, pleural effusion, weak diaphragm,
atelectasis
AUSCULTATION
a. Normal breath sounds
b. Intensity of breath sounds
c. Adventitious sounds
d. Vocal fremitus
a. Supraclavicular areashift to the bell
Characteristics of Breath Sounds
Duration of
sounds
Intensity of
expiratory
sounds
Pitch of
expiratory
sound
I:E Location
where
heard
normally
Vesicular Inspiratory
sounds last
longer than
exoiratory
Soft loud 3:1 breezy over the
most of
both lungs
Bronchovesicular Inspiration
and
expiration
are equal
intermediate 1:1 breezy/tubular Often in th
1st
and 2nd
interspaces
ant. And
bet scapula
bronchial
2:3
hollow/tubular/
hood
Over
manubrium,
head at allTracheal 5:6
tubular/loud/harsh
Over
trachea and
neck
Normallybronchial breath sounds are not heard
Adventitious lung sounds abnormal discontinuous crackles
Continuous wheezesbronchi stridor
other: pleural friction rub mediastinal crunch
Discontinous sounds (crackles)
a. Intermittent, non-musical and brief like dots
b. Fine crackles- soft high pitched and very brief 5 to 10 msec
c. Coarse crackles- louder, lower in pitch not quite so brief 20-30msec
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Cracklesresults from tiny exploration when small airways deflated during expiration, pop
open during inspiration
Late Inspiratory cracklesusually fine, profuse, and persist from breath to breath
appear first as long bases spread upward as condition loosens shifts
to dependent regions with in posturecauses: interstation lung disease
Early inspiratory crackles- appears and end soon after the start of inspiration. Often
coarse and selectively low expiratory crackles are sometimes
associated
causes:chronic bronchitis and asthma
Mid Inspiratory and expiratory cracklesbronchiectasis
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B R E A S T
From sternum to mid-axillary line
Triangular in shape
Overlies pectoralis major
Inferior border : inferior serratus
15 to 20 lobules; each lobule opens in the nipple
Areolar surface is rounded, not smooth
Palpation
Soft, but often feels granular, nodular or lumpy
Uneven texture is normal and may be termed physiologic nodularity
Nodularity may increase before mensesa time when breast often enlarges and
become tender or even painful
Supernumerary nipple
Lymphatics Pectoral nodesanteriorly located along lower border of pectoralis major or inside
anterior axiillary fold
Subcapsular node
Lateral node
Central nodemost commonly palpated lymph node along the axilla
Palpable masses of breast
Age Common Lesion Characteristics
15-20 Fibroadenoma Fine, round, mobile, tender
25-50 Cysts
Fibrocystic changes
Cancer
Soft to firm, round, mobile,tender
Nodular, rope-like
Irregular, stellate, firm, not
clearly delineated from
surrounding tissue
>50 Cancer until proven otherwise As above
Pregnancy/Lactation Lactating adenomas, mastitis
and cancer
As above
NOTE: As you grow older, risk of breast cancer increases.
Risk Factors
Risk Risk Factor
>4.0 Female
Age (65 vs. 30 yrs)
Early menarche (
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Late menopause (>55 yrs)
No full-term pregnancies
Never breast-fed a child
Factors that affect circulating hormones Recent oral contraceptive useRecent and long-term use of hormonal
replacement
Obesity (postmenopausal)
Other factors Personal history of endometrium, ovary, or
colon cancer
Alcohol consumption
Height )tall)
High socioeconomic status
Jewish
Modifiable risk factors
Post-menopausal obesity
Use of HRT (estrogen-progesterone combination)
Alcohol use
Physical inactivity
Contraceptive
Breast feeding (decrease risk)
Criteria for identifying women at risk for BRCA1 or BRCA2 mutation
Establish one of the ff risk factors:
1. 2 relatives with diagnosis of breast Ca before age 50 and 1 is first degree relative
2. 3 relatives with diagnosis of breast Ca, and occurred before age 50.
3. 2 relatives with diagnosis of ovarian Ca and 1 relative with breast Ca
Risk of Breast Ca and Histology of benign breast Ca
No increased risk, relative risk is approx. 1.3 Non-proliferative changes: cysts, ductal
ectasia, mild hyperplasia, simple
fibroadenoma, mastitis, granuloma, diabetic
mastopathy
Small increased risk, or relative risk 1.5-20 Proliferative without atypia: usual ductal
hyperplasia, complex fibroadenoma,
papilloma
Moderate increased risk, or relative risk 2.0
to approx. 4.2
Proliferative with atypia: including atypical
ductal hyperplasia and atypical loular
hyperplasia
Criteria for classifying breast Ca risk and referrals for breast MRI
High risk (20-25%) Moderate (15-20%)
BRCA1 or 2 mutation
Lifetime risk of 20-25% using assessment toolsHigh risk of genetic syndrome
History of breast Ca, ductal carcinoma in situ
Extremely dense breast
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SCREENING
Monthly self examination
Clinical breast examas early as 20 y.o.
o Every 3 years for women 20-40 y.o
o Annually after 40 y.o.
Mammographyo Every 1-2 yrs. for women in 40s
o Annually for women 50 y.o.
MRI
o Recommended for high risk individuals (20% or more), younger women with
dense breast, and contralateral breast with newly diagnosed breast Ca
o Help detect multicentric lesions and contralateral breast Ca
BREAST DISCHARGE
Spontaneous or induced Bilateral or unilateral
Physiologic hypersecretion
o Pregnancy
o Lactation
o Chest wall stimulation
o Sleep
o Stress
Galactorrhea
o Pituitary adenoma (> 100 mg/ml of prolactin)
o Physiological stimulation: sucking, pregnancy, mechanical stimulation of nipples
o
Breast trauma:
Thoracoplasty
Pneumonectomy
Mammoplasty
Trauma to chest wall
Herpes Zoster
Serous, Bloody or Opalescent Fluid
Benign condition
o Fibrocystic disease
o
Intraductal papillomao Sclerosing adenosis
o Chronic cystic mastitis
o Duct ectasia
o Galactocele
o Papillary cystadenoma
o Breast abscess
o Keratosis of nipple
o Fat necrosis
o Acute mastitis
o
TBo Toxoplasmosis
o Eczema of nipple
Malignant condition
o Breast Carcinoma
o Adenofibrosarcoma
o Fibrosarcoma
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o Neurosarcoma
o Paget disease of nipplebloody discharge, eczema-like lesion
Examination of the nipple
o Inspect for supernumerary nipples
o
Check for retraction of the nipplesign of malignancyo Look for fissureslactating females
o Look for dry scalingPagets disease
o Search for red excoriation
o Search for discharge
o Palpate the periphery of the areola for tender nodules or cors
Pituitary adenomalactation of non-pregnant women.
Papillomabenign which can cause bleeding
Inspection
Sitting position (four views) Appearance of the skin
o Color
o Thickening of the skin and unusually prominent pores
o Size and symmetry of the breast
Slight difference in size in right and left breast
Contour of the breast
o Masses, dimpling, flattening
Characteristic of the nipple
o Size, shape, direction in which they point or ulceration or any discharge
Palpation
Best performed when breast tissue is flattenedsupine.
Palpate an area extending from the clavicle to the inframammary fold and from the
midtsternal line to the posterior axillary line and well into the axilla for the tail of breast.
o Ideal time: level of hormones are at the lowest
o Nodularity increases when hormones are increased
To palpateuse finger pads of 2
nd, 3
rd, 4
thfingers which slightly flexed
Be systematicpattern of palpation like circular, linear, vertical
o Circular 0 most preferred technique
Palpate in small, concentric circles at each examination point applying the needed
pressure
2 weeks prior the onset of blood flow (menses)peak of hormonal level If 30-day cycle16
thday is the peak
If 28-day cycle14th
day is the peak
Consistency of breast tissue
Tenderness
Nodule
Locationbased on four quadrants
Size
Shapeif irregular, increased risk of malignancy
Consistency
o
soft cystic (non-malignant)o hard (malignant)
Delimitation
o border of mass/nodule
more distinct margins benign
indistinct margins malignant
tendernessnot a sign of malignancy
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mobilitynot a sign of malignancy
palpate for lymph node especially central lymph node
- END -
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Recommended