Chest to abdomen

• Thorax is the portion of the body extending from the base of the neck superiorly to the level of the diaphragm inferiorly.
• The thoracic cage is the outer structure of the thorax
• crepitus, also called subcutaneous emphysema, is a crackling sensation that occurs when air passes through fluid or exudate.
• fremitus are vibrations of air in the bronchial tubes transmitted to the chest wall
• ask the patient to say "ninety-nine" when assessing for fremitus
• the distance when assessing chest expansion, examiner's thumbs should move 5 - 10 cm apart
• when percussing for tone, healthy lung is resonance, scapula is flat, and liver is dull
• posterior thorax

  10 palpation

  22 percussion

  20 auscultation
• when percussing for diaphragmatic excursion, distance between lung and diaphragm should be 3 - 5 cm
• 3 types of breath sounds

  bronchial in neck

  bronchovesicular in sternum

  vesicular in lungs
• crackles, aka rales, are discrete and discontinuous sounds
• wheezes, aka rhonchi, are musical and continuous sounds
• when auscultating for voice sounds:

  bronchophony - ninety-nine

  egophony - letter E

  pectoriloquy - 1,2,3
• Pectus excavatum, aka funnel chest, is a markedly sunken sternum and adjacent cartilages
• Pectus carinatum, aka pigeon chest, is a forward protrusion of the sternum causing the

  adjacent ribs to slope backward.
• anterior chest

  8 palpations

  10 percussions

  10 auscultations
• The breasts are paired mammary glands that lie over the muscles of the anterior chest wall, anterior to the major and serratus anterior muscles.
• The upper outer quadrant, which extends into the

  axillary area, is referred to as the tail of Spence.
• if you do not hear any sounds when auscultating in the abdomen, try again after 5 minutes
• Lymph nodes in the breast:

  Lateral - brachial

  central - midaxillary

  posterior - subscapular

  anterior - pectoral

  infraclavicular

  supraclavicular
• peau d'orange is the orange peel appearance of breast resulting from edema
• paget's disease is a redness, mild scaling and flaking of nipple
• dimpling suggest malignancy in breast
• Supernumerary nipples may appear along the embryonic “milk line.”
• levels of pressure as you palpate the breast

  Light - superficial

  Medium - mid-level tissue

  Firm - to the ribs
• patterns of palpating the breast: circular, wedge, and vertical strip
• Fibroadenomas are usually 1–5 cm, round or oval, mobile, firm, solid, elastic, nontender, single or multiple benign masses found in one or both breasts.
• Lipomas are a collection of fatty tissue that may also appear as a lump.
• Intraductal papilloma is a small growth inside a milk duct of the breast, often near the areola. It is harmless and occurs in women ages 35 to 50.
• cancerous tumors are irregular, firm, hard, not defines masses that may be fixed or mobile. usually tender and occur after age 50
• benign breast disease, aka fibrocystic breast disease is marked by round, elastic, defined, tender, and mobile cysts. common in age 30 to menopause
• Aortic - second intercostal space at the right sternal border, base of the heart
• Pulmonic - second or third intercostal space at the left sternal border, base of the heart
• Erb's - third to fifth intercostal space at the left sternal border
• Tricuspid - fourth or fifth intercostal space at the left sternal border
• Mitral or Apical - fifth intercostal space near the left midclavicular line, apex of the heart
• Accentuated apical impulse - sign of pressure overload, increased force and duration
• laterally displaced apical impulse - sign of volume overload, apical impulse displaced laterally and found over a wider area
• murmur is a swishing sound caused by turbulent blood flow through the heart valves or great vessels.
• physiologic murmur is caused by a temporary increase in blood flow