Chest and Lungs 2012

8/11/2019 Chest and Lungs 2012

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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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JamL

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andChocoBoots

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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amL

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Date post:	03-Jun-2018
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Chest and Lungs 2012

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