Exam 2 Flashcards
What is breast tissue composed of?
glandular tissue in 15-20 lobes, suspensory ligaments (cooper’s), fat and adipose tissue
Axillary lymph nodes
central, pectoral, subscapular, lateral
supernumerary nipple
extra nipple along mammary ridge
tanner stage 1
pre-adolescent, elevation of nipple
tanner stage 2
breast bud stage, elevation of breast and nipple, enlargement of areola
tanner stage 3
further enlargement of breast and areola, menarchy
tanner stage 4
projection to form a second mound above the level of breast, menarchy
tanner stage 5
mature stage, projection of nipple only/areola recedes to level of breast
breast cancer risk factors
female over 50, personal and family history, BRCA 1/2 mutation, previous breast irradiation, menarche 50
breast cancer lifestyle risk factors
no kids or first kid after 30, long term hormone replacement therapy, alcohol 2-5 drinks daily, obesity, high fat diet, physical inactivity, not breast feeding
how long should a thorough breast exam take
3 min/breast
if lump is present what should be recorded
location, size, shape, consistency, mobility, distinctness, nipple, overlying skin color, tenderness, lymphadenopathy
gynecomastia
enlargement of flat disc of undeveloped breast tissue underneath male nipple
fibroadenomas
in age 15-25, usually single but can be multiple, well delineated, mobile, usually nontender, usually benign tumor
fibrocystic breast disease
age 30-50, regress after menopause except with estrogen therapy, round, well delineated, mobile, usually tender, lots of discomfort, single or mobile
Breast cancer
age 30 and older, most common in over 50, usually singular, irregular or stellate, firm or hard, not clearly delineated, can be fixed to skin or underlying tissues, usually nontender, usually ductal
peau d’or·ange
edema of breast, a pitted or dimpled appearance of the skin, especially as characteristic of some cases of breast cancer or due to cellulite
nipple retraction
suspensory ligament tightened up, possibly from breast cancer
Manubriosternal angle/angle of louis
important landmark for heart and lungs, site of trachea splitting, corresponds with the top of the heart, distinct bony ridge hooked to second rib
right lung fissures
oblique and horizontal
left lung fissures
oblique fissure
visceral pleurae
lines lungs
parietal pleurae
lines chest wall
functions of the lungs
supply O2 for energy production, remove CO2 as a waste product, maintain acid/base balance of arterial blood, maintain heat exchange
hypercapnia
increased CO2 in the blood increases breathing
hypoxemia
increased respirations due to an abnormally low concentration of oxygen in the blood
hypoventilation
low RR causes CO2 to build up –> respiratory acidosis
hyperventilation
rapid RR, low concentration of CO2
hacking cough is a sign of?
pneumonia
rust colored sputum
TB or pneumococcal pneumonia
frothy pink sputum
pulmonary edema
hemoptysis
coughing up blood due to TB, pulmonary embolus or heart failure, mitral valve stenosis due to increased pulmonary venous congestion (most common cardiac cause), pulmonary infarction, ruptured vessel
barrel chest is a sign of?
emphysema
Pectus excavatum
depressed breast bone, only an issue if it blocks lung expansion
Pectus carinatum
protruding breast bone
Kyphosis
tends to happen with older people because of osteoperosis/break down of spinal column, can affect ability to hear their breath sounds
scoliosis
sideways curvature of the spine
Anteroposterior: transverse diameter
1:2
coastal angle
should be
pink puffer
COPD, emphysema, chronic bronchitis, pink complexion + shortness of breath + tripod position
blue bloater
cyanosis, decreased capacity of lungs, right sided heart failure, COPD
tachypnea
> 20 RR, rapid breathing due to exercise, fever or acidotic
Kussmual
deeper rapid breathing, associated with metabolic acidosis
Cheyene-Stokes
respirations wax/wayne in a regular pattern, periods of apnea
where to palpate for symmetric expansion
T9 or T10
Tactile fremitus
Sound is conducted better through a dense or solid structure than porous so anything that increase density of lung will increase fremitus
Increased fremitus could be a sign of
pneumonia
decreased fremitus could be a sign of
obstructive bronchitis
bronchovesicular sounds
Inspiration = expiration, heard mid chest and between scapula
vesicular sounds
soft and low pitched, heard on most of lung surface, Inspiration > expiration
Bronchophony
tactile fremitus is abnormally clear rather than muffled, could be caused by the solidification of lung tissue (lung cancer) or fluid in the alveoli (pneumonia)
Egophony
E to A changes, increased resonance often caused by lung consolidation and fibrosis, could indicate pneumonia
Whispered Pectoriloquy
louder clear whispered “99“ rather than faint or absent sound, could be a sign of pneumonia or cancer
infants have a rounded thorax until?
age 6
infants breath through nose rather than mouth until
age 3 months
infant RR
30-40 breaths / min
infants have bronchovesicular sounds in peripheral lung field until
age 6
older adult chest changes…
increased AP:transverse, kyphosis, compensates by holding head extended and tilted back, decreased chest expansion, fatigue easily
atelectasis
partial or complete collapse of the lung usually due to anesthesia
atelectasis signs
trachea may be shifted towards involved side, absent tactile fremitus, dull percussion over affected area, absent breath sounds
Consolidation (pneumonia) signs
trachea is midline, increased tactile fremitus over affected area, dull percussion, bronchial breath sounds, late inspiratory crackles over involved area
bronchitis signs
trachea is midline, normal tactile fremitus, resonant percussion, vesicular breath sounds, possibly scattered coarse crackles or wheezes or rhonchi
emphysema
damaged alveoli
emphysema signs
trachea is midline, decreased tactile fremitus bc alveoli can’t get the air out so more trapped in lungs, hyperresonant percussion, decreased breath sounds to absent, possible scattered crackles, wheezes and rhonchi
bronchitis
inflammation of lining of bronchial tubes
pneumonia
fluid filled, infection of alveoli
asthma signs
trachea is midline, decreased tactile fremitus, resonant or hyperresonant percussion, breath sounds obscured by wheezes, possible crackles
asthma
Constriction in trachiobronchial tree & edema & mucus & bronchospasm, lungs will over inflate during asthma attack
pleural effusion
A buildup of fluid between the tissues that line the lungs and the chest, collapses the alveoli
pleural effusion signs
trachea shifted toward opposite side, decreased to absent tactile fremitus, dull to flat percussion, decreased to absent breath sounds, possible pleural friction rub
pneumothorax
collapsed lung usually due to injury - either air leaking into pleural space or a leak in the chest wall
pneumothorax signs
trachea shifted toward opposite side, decreased tactile fremitus due to pleural air, hyperresonant percussion, decreased to absent breath sounds, possible pleural rub
congestive heart failure signs
trachea is midline, decreased tactile fremitus, resonant percussion, vesicular breath sounds, possible crackles and wheezes
where is the apical pulse?
5th intercostal space in adults and 4th in children, midclavicular line, point of maximal impulse
what is S1
closing of AV valves during systole, ventricles contract, mitral closes before tricuspid
what is S2
closing of semilunar valves during diastole, ventricles relax, aortic closes before pulmonic
where is S1 loudest
apex of the heart
where is S2 loudest
loudest at the base
S3
aka ventricular gallop, occurs when ventricles are resistant to early rapid filling (protodiastolic) bc they are stiff, occurs right after S2 when atrial blood is flowing in, one of the first signs of CHF, can be normal in the young or pregnant
S4
aka atrial gallop, occurs at the end of diastole (atrial kick), when ventricles are resistant they vibrate, occurs right before S1, pathological but can sometimes happen in athletes
what can cause a murmur
increased blood velocity, thinner blood, structural defect in valve
what is normal CO
4-6L of blood/min
cardiac output formula
strove volume x heart rate
blood pressure formula
CO x systemic vascular resistance
preload
volume of venous return during diastole
afterload
the pressure the ventricle has to overcome to pump it’s blood
Where do men feel heart attacks
sternal chest pain, jaw and left arm
where do women feel heart attacks
back pain
hematemesis
old blood vomit
visceral pain
when hollow organs forcefully contract or become distended or when solid organs swell against their capsules
what does visceral pain feel like
gnawing, cramping, aching, difficult to localize
epigastric pain?
stomach
RUQ pain
liver or gallbladder
pain by belly button
appendix
pubic/sacral pain
rectum, colon, bladder, uterus
parietal pain
inflammation from the hollow or solid organs that affect the parietal peritoneum, more severe and not easily localized
referred pain
originates at different sites but shares innervation from the same spinal level
abdominal pain could be referred to
shoulder
heart pain and GERD could be referred to
left arm
kidney stones or renal colic could be referred to
back
hematochezia
blood in stool
melena
black, tarry stool, indicates blood in colon or higher up
ventral hernia
defects in abdominal wall through which tissue protrudes
lipoma
common, benign, fatty tumors usually located in subcutaneous tissue, soft and often lobulated, slips out from under finger when pressed down
epigastric hernia
defect in linea alba
incisional hernia
protrusion through operational scar
umbilical hernia
defect in umbilical ring
aortic pulse in epigastric area
amplitude is increased with aneurysm or solid structure
borborygmi
intestinal rumbling
order of assessment for abdomen
inspect, auscultate, percuss, palpate
where to start auscultating bowel sounds
ileocecal valve in RLQ
Auscultate vascular sounds in abdomen at
aorta, L&R renal arteries, L&R iliac arteries, L&R femoral arteries
arterial bruits with systolic and diastolic components is a sign of
partial occlusion of aorta or large arteries
liver span on midclavicular line
6-12cm
what could cause enlarged liver
chf, hepatitis
liver scratch test
define liver borders when abdomen is tense or distended, place stethescope over liver and scratch over RLQ, when sound is magnified that is the liver edge
costovertebral tenderness
pressure from fingertips can produce tenderness due to kidney infection but may also be musculoskeletal
normally palpable abdominal structures
full bladder, sigmoid colon with feces, ascending colon, fetus, edge of liver, lower right kidney
abnormal palpable abdominal structures
descending colon, enlarged liver, enlarged spleen (3x), enlarged nodular liver, enlarged gallbladder, enlarged kidney
signs of aorta aneurysm
decreased femoral pulses, aorta width is >5cm, bruit
how to assess for acute cholecystitis
murphy’s sign - palpate for liver and if patient can’t exhale it is a positive sign for inflamed gallbladder
how to assess for appendicitis
rebound tenderness, rovsing’s sign (push on LLQ and pain will radiate to RLQ), psoas sign (have pt lift up leg against pressure, if there is pain in abdomen that is a positive sign), obturator test (internal/external rotation of hip, pain in abdomen is a positive sign)
how to assess for ascites
protuberant abdomen with bulging flanks, percuss abdomen and if there is ascites flanks will be dull
a sign of peritonitis
rebound tenderness
myocardial ischemia
oxygenated blood supply is not getting to the myocardium, usually occurs when metabolic supply of the body increases
myocardial infarction
blood supply is cut off by a clog
anasarca
can happen with kidney/liver/heart failure, generalized edema everywhere
chest lift is a sign of
ventricular hypertrophy, lifts with systole
right ventricular hypertrophy could be seen
sternal border
left ventricular hypertrophy could be seen
apex
mitral valve location
5th intercostal space, midclavicular line
tricuspid valve location
5th intercostal space, near sternal border
pulmonary valve location
2nd intercostal space, left sternal border
aortic valve location
2nd intercostal space, right sternal border
physiologically split S2 is
normal during inspiration, aortic closes before pulmonic because there is more blood in the lungs so less blood in the left side
valve stenosis occurs when
valve is opening
valve regurgitation occurs when
valve is closing
what is the worst kind of murmur
diastolic
mitral valve prolapse sign
midsystolic click and murmur
3 differences in fetal heart
ductus venosus (hepatic bypass that compensates for the fact the baby is getting blood from umbilical vein instead of own body), foramen ovale (opening between R and L atrium, closes when o2 hits baby’s lungs), patent ductus arteriosis (shunts blood from pulmonary artery to aorta to bypass lungs)
intermittent claudication
a condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries
myocardial ischemia causes of chest pain
stable (typical) angina, unstable angina, variant angina, myocardial infarction
mitral valve prolapse
one or both leaflets prolapse back into atria during systole
pericarditis
inflammation of the pericardium caused by a virus/bacteria/uremia/lupus/neoplasm may cause precordial chest pain, pain is crushing in the retrosternal area
dissecting aneurysm
tearing of arterial intima (inner layer of aorta) which causes blood to surge through the tear and the layers dissect, tearing pain radiating to back or neck
pulmonary embolism
dyspnea, but can be asymptomatic, blood clot in lungs that can travel
pleurisy
inflammation of pleura, gets worth when breathing and better when holding breath
pulmonary hypertension
dyspnea, uncomfortable nonradiating constriction across chest
mediastinal emphysema
free air in the mediastinum produces chest tightness and dyspnea, hamman’s sign can be heard over precordium
esophageal spasm
substernal pain and dysphagia, may mimic angina
esophageal reflux
substernal burning or cramping radiates into arms, neck, jaw, can be relieved with antacids
gallstone colic
RUQ pain radiating to back or right shoulder or chest
dyspnea
shortness of breath, uncomfortable awareness of breathing
orthopnea
dyspnea when laying down, relieved by sitting up
paroxysmal nocturnal dyspnea
dyspnea after laying down for a few hours, wake up with SOB
pulmonary edema
pulmonary congestion bc of left sided heart failure, anxious dyspnea
Paroxysmal atrial tachycardia
period of rapid heart beat that begins and ends suddenly
ectopic beats
disturbance to heart rate because of electrical problem
cardiac syncope causes
arrhythmia that reduces SV, cardiac outflow obstruction, ischemia, carotid sinus syncope, hypovolemia
central cyanosis
decreased pulmonary venous saturation (tetralogy of fallot in children)
fatigue caused by decreased CO is worse when
evening
fatigue caused by anxiety/depression is worse when
in the morning
Orthostatic hypotension causes
vascular volume loss, redistribution of blood volume, prolonged bedrest, vasovagal fainting, ANS dysfunction
orthostatic hypotension
systole decreases no more than 15 mmhg and HR increases up to 10 beats/min when changing from supine to standing
what would displace the PMI downward and left
left ventricular dilation (volume overload)
what would increase the force and duration of PMI
left ventricular hypertrophy
the bell of the stethoscope picks up
S3 and rumble of mitral stenosis
the diaphragm of stethoscope picks up
S1, S2 and S4
S1 coincides with
carotid artery pulse
early systolic ejection click is a sign of
aortic stenosis, pulmonic stenosis
opening snap is a sign of
mitral stenosis
newborn HR and BP
higher and lower
JVP reflects
right atrial pressure, clinical indicator of cardiac function and right heart hemodynamics
normal JVP
8-9cm
peripheral arterial disease
common circulatory problem in which narrowed arteries reduce blood flow to your limbs, intermittent claudification
venous peripheral vascular disease
swelling in limbs
allen test
depress radial artery with closed fist, open back up, should pink back up via ulnar artery, if it doesn’t it is occluded
chronic arterial insufficiency signs
claudification, decreased pulses, pale or dusky red on dependency, cool, mild or absent edema, thin/shiny skin, loss of hair and thickening toenails, ulcers on toes or points of trauma, possible gangrene
chronic venous insufficiency signs
no pain or aching, normal pulses, cyanotic on dependency, brown pigmentation, normal temp, edema, ulcers on sides of ankles, no gangrene
homan’s sign
left pts leg and flex the foot, if there is deep calf pain that could be a sign of DVT, very unreliable
