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nr 509 final exam lunde summary advanced physical assessment.
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NR 509 Final Exam Study GuideChapter 18 Breasts and Axillae
Techniques of examina 琀椀 on
o best 琀椀 me = while menstrua 琀椀 ng 5-7 days a 昀琀 er menstrual onset
breasts swell and become more nodular before menses from increased
estrogen. Re evaluate nodules palpated on premenstrual exam for a 昀琀 er
menstural onset
o inspect the breast in 4 views – arms at sides, arms over head, arms pressed
against and leaning forward
to assess for dimpling/retrac 琀椀 on, have pa 琀椀 ent raise their arms over
then pres hands against hips to contract pectoral muscles
o palpate breast while supine
o inspect axillae while si 琀� ng
Anatomy
o Montgomery glands = sebaceous glands on areola
o Female breast lies against the anterior thoracic wall, extends from the clavicle and
second rib down to the sixth rib and from the sternum to the midaxillary line
o Fibroadenoma
15-25 years old
Single or mul 琀椀 ple
Round disc like or lobular, small 1-2 cm
May be so 昀琀 but usually 昀椀 rm
Well delineated
Very mobile
Nontender
No retrac 琀椀 on signs
o Cysts
30-50 years
Single or mul 琀椀 ple
Round
So 昀琀 to 昀椀 rm, elas 琀椀 c
Well delineated
Mobile
Tender
No retrac 琀椀 on signs
o Cancer
30-90 years – most common >50
Usually single but may coexist with other nodules
Irregular or stellate shape
Firm or hard
Not clearly delineated from surrounding 琀椀 ssues
Fixed to skin or underlying 琀椀 ssues
Nontender
May have retrac 琀椀 on signs
, Breast cancer causes scar 琀椀 ssue ( 昀椀 brosis) and shortening of th
dimpling, changes in contour, and retrac 琀椀 on or devia 琀椀 on of th
Female breast/axillae assessment
o Palpable lumps, nodularity, and premenses enlargement & tenderness are commo
o Mastodynia / mastalgia = breast pain
Medica 琀椀 ons can increase breast pain
Hormone replacement therapy
psychotropics like SSRIs
haloperidol spironolactone
digoxin
o nipple redness = local infec 琀椀 on/in 昀氀 ammatory carcinoma
o thickening and prominent pores = peau d’orange = breast cancer
o 昀氀 a 琀琀 ening of normally convex breast = cancer
o asymmetry with change in nipple direc 琀椀 on – cancer
o eczematous changes with rash/scaling/ulcera 琀椀 on on the nipple extending to th
paget disease of the breast = underlying ductal or lobular carcinoma
o nipple pulled inward and tethered by underlying ducts = nipple retrac 琀椀 on ( 昀氀 a
thickened) = cancer
o breast retrac 琀椀 on/dimpling = cancer
cancers with 昀椀 brous strands a 琀琀 ached to the skin/fascia over the pec
muscles = inward dimpling during contrac 琀椀 on
can be benign, pos 琀琀 rauma 琀椀 c fat necrosis or mammary duct ectasia
o tender subareolar cords = mammary duct ectasia = benign painful dila 琀椀 on of
surrounding in 昀氀 amma 琀椀 on & masses
o hard irregular poorly circumscribed nodules 昀椀 xed to the skin or 琀椀 ssues = ca
o mobile mass that becomes 昀椀 xed when the arm relaxes is a 琀琀 ached to the ri
intercostal muscles
if 昀椀 xed when hands press against hip = a 琀琀 ached to pectoral fascia
o thickening of nipple and loss of elas 琀椀 city = cancer
o sweat gland infec 琀椀 on from follicular occlusion = hidradeni 琀椀 s suppura 琀椀 v
o deeply pigmented velvety axillary skin = acanthosis nigricans
= diabetes/obesity/PCOS/malignant paraneoplas 琀椀 c disorders
o nodes that are large (>1 -2 cm) and 昀椀 rm / hard / ma 琀琀 ed together / 昀椀 xe
underlying 琀椀 ssues = malignancy
o post breast surgery – masses/nodularity/color changes/in 昀 氀 amma 琀椀 on especial
the incision line = breast cancer recurrence
Lymph nodes – 6 groups
o Anterior (pectoral) group
Receive from anterolateral abdominal wall above umbilicus
Grasp anterior axillary fold between thumb and 昀椀 ngers, and palpate insi
pectoral muscle border
o Posterior (subscapular) group
Receive from the back, as far down as iliac crests
Step behind pa 琀椀 ent and with 昀椀 ngers feel inside muscle of posterior a
o Lateral (humeral or deep) group
Receive most lymph vessels of upper limb
High in the axilla, feel along upper humerus
, o Central group
Most likely to be palpable
Receive from anterior/posterior/lateral
Located in the Ro 琀琀 er Space – between pectoralis minor and major
One or more so 昀琀 small less than 1 cm nontender nodes frequently felt
o Apical (terminal) group
Final common pathway for all axillary lymph nodes
o Infraclavicular (deltopectoral) group
Not strictly axillary
Super 昀椀 cial vessels from lateral arms
The male breast
o Gynecomas 琀椀 a – benign breast enlargement more than 2 cm
Pseudogynecomas 琀椀 a – accumula 琀椀 on of subareolar fat
Caused by increased estrogen, decreased testosterone, and medica 琀椀 on
Not risk factor for breast cancer
o Hard irregular eccentric ulcera 琀椀 ng painless dominant mass = cancer
Breast cancer (including screening and risk factors)
o Screening recommenda 琀椀 ons
Biennial mammography screening for women 50-74
Women below 50 with a parent/sibling/child with breast cancer may start
mammography sooner
o Risk factors
Increased age, 昀椀 rst degree family member, inherited gene 琀椀 c muta 琀
breast cancer/ductal/lobular carcinoma in situ, denser breasts/high levels of
endogenous hormones/high dose radia 琀椀 on to the chest while young
Gail model = breast cancer risk assessment tool
Clinical breast examina 琀椀 on (CBE) and self-breast examina 琀椀 on (SBE) techniques
o At least 3 minutes for each breast
o Use pads of the second, third, and fourth 昀椀 ngers, Palpate small concentric circ
ver 琀椀 cal strip pa 琀琀 ern applying light medium and deep pressure at each poin
Physiologic changes associated with the normal aging process
o Nodular ropelike masses = 昀椀 brocys 琀椀 c changes
o A 昀琀 er menopause, atrophy of glandular 琀椀 ssue = decrease in # of lobules
Lacta 琀椀 on
o galactorrhea = discharge of milk containing 昀氀 uid not r/t pregnancy = hyperprola
c/b hyperthyroidism, pituitary prolac 琀椀 noma, dopamine antagonists,
psychotropics, and phenothiazines
o spontaneous unilateral bloody discharge from one or two ducts warrants = intradu
papilloma / ductal carcinoma in situ / paget disease
o clear / serous / green / black / nonbloody discharge that are mul 琀椀 ductal = ben
Chapter 19 Abdomen
Techniques of examina 琀椀 on
o Alarm symptoms
Dysphagia, odynophagia, recurrent vomi 琀椀 ng, GI bleeding, early sa 琀椀 e
loss, anemia, RF gastric cancer, palpable mass, painless jaundice
, o s/s of GI disorders
abdominal pain
visceral pain
when hollow abdominal organs like the intes 琀椀 ne/biliary tree
contract forcefully or are distended
visceral pain is typically nonspeci 昀椀 c and di 昀 cult to localiz
pain typically progresses with systemic symptoms, swea 琀椀 n
pallor, N/V, restlessness
visceral pain in RUQ = liver disten 琀椀 on (hepa 琀椀 s) or biliar
pathology
visceral periumbilical pain = acute appendici 琀椀 s – changes t
parietal pain in RLQ
pain dispropor 琀椀 onate to physical 昀椀 ndings = intes 琀椀 n
mesenteric ischemia
soma 琀椀 c or parietal pain
originates from in 昀氀 amma 琀椀 on of parietal peritoneum =
peritoni 琀椀 s
steady aching pain that is usually more severe than viscerlal p
and more localized over involved structure
colicky pain from renal stones = pa 琀椀 ent will move
around to 昀椀 nd comy posi 琀椀 on
referred pain
distant sites that are innervated at spinal levels
develops as ini 琀椀 al pain becomes more intesnse and radiate
palpa 琀椀 on at site of referred pain does not result in tendern
pain of duodenal or pancrea 琀椀 c origin may be referred to th
back
pain from the biliary tree radiate to the right scapular region o
right posterior thorax
pain from pleurisy or inferior wall myocardial infarc 琀椀 on ma
referred to epigastric area
angina may present as indiges 琀椀 on but is precipitated
exer 琀椀 on and relieved by rest
pain may be referred to the abdomen from chest, spine, or
pelvis
dyspepsia = chronic or recurrent pain in upper abdomen characterize
by epigastric burning or pain or both and postprandial fullness or ear
sa 琀椀 ety or both
may also be accompanied with nausea, bloa 琀椀 ng, belching
func 琀椀 onal or non ulcer dyspepsia – 3 month nonspeci 昀椀 c
abdominal discomfort or nausea not r/t PUD or strucrural
abnormali 琀椀 es
c/b delayed gastric emptying, PUD with or w/out
h pylori, and h pylori, IBS, and psychosocial
chronic upper abdominal pain typically has heartburn,
dysphagia, and e 昀昀 ortless regurgita 琀椀 on
indiges 琀椀 on, nausea, vomi 琀椀 ng, hematemesis, anorexia, early sa 琀椀
dysphagia, odynophagia
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