NR 509 Final Exam Study Guide
Chapter 18 Breasts and Axillae
Techniques of examination
o Arms over head
Can bring out dimpling or retraction that may be invisible Palpate the breasts
Best with pt. supine
A thorough examination takes at least three minutes
Use the vertical strip pattern to detect breast mass
Palpate in small, concentric circles applying light, medium, and deep pressure at
each examining point
When pressing deeply on the breast a normal rib can be mistaken for a hard
breast mass
To palpate lateral breast, ask patient to roll onto the opposite hip, placing her
hand on her forehead but keeping the shoulder pressed against the bed or
examining table as this flattens the lateral breast tissue.
To palpate the medial portion of the breast, have pt. lie flat with shoulders
against the examining table
Inspect the axillae
Palpate the axillary nodes
By moving in a straight line down the bra line, then move fingers
medially and palpate in a vertical trip up the chest to the clavicle.
Anatomy
o
Female breast/axillae assessment
o Breast lump or mass
Can be physiologic or pathologic ranging from cysts and fibroadenomas to breast
cancer
o Breast cyst
Usually firm, round, mobile, and often tender, mostly common between ages of
25-50 years old
o Breast discomfort or pain
SSRI, Haldol, Aldactone, and dig can cause breast pain Nipple discharge
o
Lymph nodes
o The lymphatic drainage of the breast is of great importance in the spread of carcinoma,
and about three-quarters of it is to the axillary nodes.
Central nodes (axillary)
o
The male breast
o Gynecomastia: males who develop benign breast enlargement. Causes include increased
estrogen, decreased testosterone, and medication side effects
o Inspect the nipple and areola (nodules, swelling, ulceration)
o Palpate the areola and breast tissue (nodules)
Breast cancer (including screening and risk factors)
, o Redness suggests local infection or inflammatory carcinoma Thickening and prominent
pores suggests breast cancer
o Flatting of the normally convex breasts suggest cancer Asymmetry in nipple direction
suggests cancer
o Eczematous changes with rash scaling or ulceration on the nipple extending to areola
suggests Paget disease
o Inverted nipple suggest cancer
o Breast dimpling or retraction suggest cancer
o Milky discharge unrelated to pregnancy is nonpuerperal galactorrhea
Caused by hypothyroidism, pituitary prolactinoma, and dopamine antagonists
o Risk factors
Increasing age 65+ until age 80
Biopsy: confirmed atypical hyperplasia
First-degree family members diagnosed with breast cancer at an early age
Inherited genetic mutations- BRCA 1 and BRCA2
Personal history of breast cancer or ductal or lobular carcinoma
Relatively denser breasts on mammography
High-dose radiation to the chest at a young age
High levels of endogenous hormones
Age at first full term pregnancy
Late menopause
o Modifiable risk factors
Breastfeeding for less than 1 year, postmenopausal obesity, use of HRT, smoking,
alcohol consumption, physical inactivity, and type of contraception.
Clinical breast examination (CBE) and self-breast examination (SBE) techniques
o The best time is in a patient who is still menstruating 5-7 days after the onset of
menstruation because breasts tend to swell and become more nodular before menses
o Inspect breasts in four views: arms at sides, arms over head, arms pressed against hips,
and leaning forward.
o Breast self-examination
A high proportion of breast masses are detected by women examining their own
breasts. For screening, the BSE has not been shown to reduce breast cancer
mortality but may promote health awareness and earlier reporting of breast
changes or masses, which may reduce unnecessary testing and biopsies
compared to monthly self-examination. The BSE is best timed 5 to 7 days after
menses, when hormonal stimulation of breast tissue is low.
Physiologic changes associated with the normal aging process
o Fibroadenoma
very mobile, round dislike, typically small (1-2cm), firm, usually single but very
well delineated. 15-25 years, puberty.
o Cyst
mobile, round, well delineated, soft to firm, single, 30-50 years.
o Cancer
may be fixed to the skin or underlying tissues, usually single, irregular or stellate
in shape, firm or hard, most common over age of 50
Lactation
o
,Chapter 19 Abdomen
Techniques of examination
o Differentials for epigastric pain
GERD
Pancreatitis
Perforated ulcers
MI
o Abdomen
Note the general appearance
Inspect the surface, contours, and movements of the abdomen including skin
temp, color, and scares or striae
Ecchymosis is seen in intraperitoneal or retroperitoneal hemorrhage.
Asymmetry suggests a hernia, enlarged organ or a mass.
Bulging flanks of ascites, suprapubic bulge, large liver or spleen, tumors.
Peristalsis waves
Increased in GI obstruction
Listen for bowel sounds
Less than 5 per minute is considered hypoactive >34 a minute is
considered hyperactive
Friction rubs
Liver tumor or splenic infarct
Percuss in all four quadrants
A tympanic abdomen throughout suggests intestinal obstruction or
paralytic ileus.
Palpate lightly then deeply
Palpating an abdominal mass
Occasionally there are masses in the abdominal wall rather than
inside the abdominal cavity.
Ask the patient to either raise the head and shoulders or to
strain down, this tightens the abdominal muscles, then feel for
the mass again.
Check for signs of peritonitis
o Liver
Estimate the size along the right midclavicular line by percussion
Palpate and characterize the liver edge
In chronic liver disease an enlarged palpable liver edge below the ribs is
suggestive of an enlarged liver and cirrhosis
Firmness or hardness of the liver, bluntness or rounding of its edge, and surface
irregularity are suspicious for liver disease
An obstructed distended gallbladder may merge with the liver, forming a firm
oval mass below the liver edge and an area that is dull to percussion
There is increased dullness with percussion in hepatomegaly from acute
hepatitis, heart failure, decreased dullness in cirrhosis
Hepatic bruit in carcinoma of the liver and alcoholic hepatitis.
o Spleen
, Percuss for splenic enlargement along the traube space
Palpate the splenic edge with the patient supine and in the right lateral
decubitus position (lying on the right side with legs flexed at hips and knees)
A change in percussion note from tympany to dullness on inspiration is a
positive splenic percussion sign, but this sign is only moderately useful for
detecting splenomegaly
Splenomegaly is 8 times more likely when the spleen is palpable
Caused by portal hypertension, hematologic malignancies, HIV infection,
infiltrative diseases like amyloidosis and splenic infarct or hematoma
o Kidneys
Check for costovertebral angle (CVA) tenderness (Flank pain)
Tenderness in pyelonephritis
Pain with pressure or fist percussion supports pyelonephritis if associated with
fever and dysuria but may also be MSK
o Urinary bladder
Blood in urine can be caused by BPH, urolithiasis, UTI, or prostate, bladder, and
kidney cancer.
Percuss for distention and tenderness
Suprapubic tenderness is common in bladder infection
Pink-purple striae are a hallmark of Cushing syndrome
Forms on incontinence
Stress incontinence
the urethral sphincter is weakened so that transient increases in
intra-abdominal pressure raise the bladder pressure to levels
that exceed urethral resistance.
Causes
childbirth, surgery, postmenopausal atrophy of
the mucosa, and urethral infection. May follow
prostate surgery in men.
Urge incontinence
detrusor contractions are stronger than normal and overcome
the normal urethral resistance. The bladder is usually small.
Mechanisms
decreased cortical inhibition of detrusor
contractions from stroke, brain tumor,
dementia, and lesions of the spinal cord above
the sacral level. Also, hyperexcitability of
sensory pathways ie: bladder infections tumors,
and fecal impaction. Deconditioning of voiding
reflexes, such as frequent voluntary voiding at
low bladder volumes.
Overflow incontinence
detrusor contractions are insufficient to overcome urethral
resistance, causing urinary retention. The bladder is typically
flaccid and large, even after effort to void.
Mechanisms
Chapter 18 Breasts and Axillae
Techniques of examination
o Arms over head
Can bring out dimpling or retraction that may be invisible Palpate the breasts
Best with pt. supine
A thorough examination takes at least three minutes
Use the vertical strip pattern to detect breast mass
Palpate in small, concentric circles applying light, medium, and deep pressure at
each examining point
When pressing deeply on the breast a normal rib can be mistaken for a hard
breast mass
To palpate lateral breast, ask patient to roll onto the opposite hip, placing her
hand on her forehead but keeping the shoulder pressed against the bed or
examining table as this flattens the lateral breast tissue.
To palpate the medial portion of the breast, have pt. lie flat with shoulders
against the examining table
Inspect the axillae
Palpate the axillary nodes
By moving in a straight line down the bra line, then move fingers
medially and palpate in a vertical trip up the chest to the clavicle.
Anatomy
o
Female breast/axillae assessment
o Breast lump or mass
Can be physiologic or pathologic ranging from cysts and fibroadenomas to breast
cancer
o Breast cyst
Usually firm, round, mobile, and often tender, mostly common between ages of
25-50 years old
o Breast discomfort or pain
SSRI, Haldol, Aldactone, and dig can cause breast pain Nipple discharge
o
Lymph nodes
o The lymphatic drainage of the breast is of great importance in the spread of carcinoma,
and about three-quarters of it is to the axillary nodes.
Central nodes (axillary)
o
The male breast
o Gynecomastia: males who develop benign breast enlargement. Causes include increased
estrogen, decreased testosterone, and medication side effects
o Inspect the nipple and areola (nodules, swelling, ulceration)
o Palpate the areola and breast tissue (nodules)
Breast cancer (including screening and risk factors)
, o Redness suggests local infection or inflammatory carcinoma Thickening and prominent
pores suggests breast cancer
o Flatting of the normally convex breasts suggest cancer Asymmetry in nipple direction
suggests cancer
o Eczematous changes with rash scaling or ulceration on the nipple extending to areola
suggests Paget disease
o Inverted nipple suggest cancer
o Breast dimpling or retraction suggest cancer
o Milky discharge unrelated to pregnancy is nonpuerperal galactorrhea
Caused by hypothyroidism, pituitary prolactinoma, and dopamine antagonists
o Risk factors
Increasing age 65+ until age 80
Biopsy: confirmed atypical hyperplasia
First-degree family members diagnosed with breast cancer at an early age
Inherited genetic mutations- BRCA 1 and BRCA2
Personal history of breast cancer or ductal or lobular carcinoma
Relatively denser breasts on mammography
High-dose radiation to the chest at a young age
High levels of endogenous hormones
Age at first full term pregnancy
Late menopause
o Modifiable risk factors
Breastfeeding for less than 1 year, postmenopausal obesity, use of HRT, smoking,
alcohol consumption, physical inactivity, and type of contraception.
Clinical breast examination (CBE) and self-breast examination (SBE) techniques
o The best time is in a patient who is still menstruating 5-7 days after the onset of
menstruation because breasts tend to swell and become more nodular before menses
o Inspect breasts in four views: arms at sides, arms over head, arms pressed against hips,
and leaning forward.
o Breast self-examination
A high proportion of breast masses are detected by women examining their own
breasts. For screening, the BSE has not been shown to reduce breast cancer
mortality but may promote health awareness and earlier reporting of breast
changes or masses, which may reduce unnecessary testing and biopsies
compared to monthly self-examination. The BSE is best timed 5 to 7 days after
menses, when hormonal stimulation of breast tissue is low.
Physiologic changes associated with the normal aging process
o Fibroadenoma
very mobile, round dislike, typically small (1-2cm), firm, usually single but very
well delineated. 15-25 years, puberty.
o Cyst
mobile, round, well delineated, soft to firm, single, 30-50 years.
o Cancer
may be fixed to the skin or underlying tissues, usually single, irregular or stellate
in shape, firm or hard, most common over age of 50
Lactation
o
,Chapter 19 Abdomen
Techniques of examination
o Differentials for epigastric pain
GERD
Pancreatitis
Perforated ulcers
MI
o Abdomen
Note the general appearance
Inspect the surface, contours, and movements of the abdomen including skin
temp, color, and scares or striae
Ecchymosis is seen in intraperitoneal or retroperitoneal hemorrhage.
Asymmetry suggests a hernia, enlarged organ or a mass.
Bulging flanks of ascites, suprapubic bulge, large liver or spleen, tumors.
Peristalsis waves
Increased in GI obstruction
Listen for bowel sounds
Less than 5 per minute is considered hypoactive >34 a minute is
considered hyperactive
Friction rubs
Liver tumor or splenic infarct
Percuss in all four quadrants
A tympanic abdomen throughout suggests intestinal obstruction or
paralytic ileus.
Palpate lightly then deeply
Palpating an abdominal mass
Occasionally there are masses in the abdominal wall rather than
inside the abdominal cavity.
Ask the patient to either raise the head and shoulders or to
strain down, this tightens the abdominal muscles, then feel for
the mass again.
Check for signs of peritonitis
o Liver
Estimate the size along the right midclavicular line by percussion
Palpate and characterize the liver edge
In chronic liver disease an enlarged palpable liver edge below the ribs is
suggestive of an enlarged liver and cirrhosis
Firmness or hardness of the liver, bluntness or rounding of its edge, and surface
irregularity are suspicious for liver disease
An obstructed distended gallbladder may merge with the liver, forming a firm
oval mass below the liver edge and an area that is dull to percussion
There is increased dullness with percussion in hepatomegaly from acute
hepatitis, heart failure, decreased dullness in cirrhosis
Hepatic bruit in carcinoma of the liver and alcoholic hepatitis.
o Spleen
, Percuss for splenic enlargement along the traube space
Palpate the splenic edge with the patient supine and in the right lateral
decubitus position (lying on the right side with legs flexed at hips and knees)
A change in percussion note from tympany to dullness on inspiration is a
positive splenic percussion sign, but this sign is only moderately useful for
detecting splenomegaly
Splenomegaly is 8 times more likely when the spleen is palpable
Caused by portal hypertension, hematologic malignancies, HIV infection,
infiltrative diseases like amyloidosis and splenic infarct or hematoma
o Kidneys
Check for costovertebral angle (CVA) tenderness (Flank pain)
Tenderness in pyelonephritis
Pain with pressure or fist percussion supports pyelonephritis if associated with
fever and dysuria but may also be MSK
o Urinary bladder
Blood in urine can be caused by BPH, urolithiasis, UTI, or prostate, bladder, and
kidney cancer.
Percuss for distention and tenderness
Suprapubic tenderness is common in bladder infection
Pink-purple striae are a hallmark of Cushing syndrome
Forms on incontinence
Stress incontinence
the urethral sphincter is weakened so that transient increases in
intra-abdominal pressure raise the bladder pressure to levels
that exceed urethral resistance.
Causes
childbirth, surgery, postmenopausal atrophy of
the mucosa, and urethral infection. May follow
prostate surgery in men.
Urge incontinence
detrusor contractions are stronger than normal and overcome
the normal urethral resistance. The bladder is usually small.
Mechanisms
decreased cortical inhibition of detrusor
contractions from stroke, brain tumor,
dementia, and lesions of the spinal cord above
the sacral level. Also, hyperexcitability of
sensory pathways ie: bladder infections tumors,
and fecal impaction. Deconditioning of voiding
reflexes, such as frequent voluntary voiding at
low bladder volumes.
Overflow incontinence
detrusor contractions are insufficient to overcome urethral
resistance, causing urinary retention. The bladder is typically
flaccid and large, even after effort to void.
Mechanisms
