Podcast
Questions and Answers
What is the main purpose of a clinical breast exam (CBE)?
What is the main purpose of a clinical breast exam (CBE)?
What percentage of breast cancer cases occur in men?
What percentage of breast cancer cases occur in men?
Why might breast changes not be indicative of cancer?
Why might breast changes not be indicative of cancer?
What is a common reason for delayed care seeking in men diagnosed with breast cancer?
What is a common reason for delayed care seeking in men diagnosed with breast cancer?
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What area does a clinical breast exam assess?
What area does a clinical breast exam assess?
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What could be a potential risk factor for breast cancer?
What could be a potential risk factor for breast cancer?
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Which sign may indicate a problem with breast health?
Which sign may indicate a problem with breast health?
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Which of the following symptoms is commonly associated with gastrointestinal issues?
Which of the following symptoms is commonly associated with gastrointestinal issues?
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What area is typically affected by pain originating from the kidneys?
What area is typically affected by pain originating from the kidneys?
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Which system is NOT typically involved in abdominal assessment?
Which system is NOT typically involved in abdominal assessment?
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What is an indication of hormonal imbalance in females that may affect the breast?
What is an indication of hormonal imbalance in females that may affect the breast?
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Which symptom is likely to complicate the diagnosis of gastrointestinal problems?
Which symptom is likely to complicate the diagnosis of gastrointestinal problems?
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Which organ's function is closely linked to the balance of fluids and electrolytes in the body?
Which organ's function is closely linked to the balance of fluids and electrolytes in the body?
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What is the average liver size measured by percussion in men?
What is the average liver size measured by percussion in men?
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In Castell’s Method, which sound is expected on expiration when percussing the spleen?
In Castell’s Method, which sound is expected on expiration when percussing the spleen?
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What is the expected size of the spleen when percussed?
What is the expected size of the spleen when percussed?
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What is a key finding when performing light palpation in all four quadrants?
What is a key finding when performing light palpation in all four quadrants?
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What position is recommended for performing splenic percussion?
What position is recommended for performing splenic percussion?
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Which of the following signs is associated with gallbladder disease during deep palpation?
Which of the following signs is associated with gallbladder disease during deep palpation?
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What is indicated if dullness is noted between the 5th and 7th intercostal spaces during examination?
What is indicated if dullness is noted between the 5th and 7th intercostal spaces during examination?
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Which condition would be suggested by tenderness or grimacing during deep palpation?
Which condition would be suggested by tenderness or grimacing during deep palpation?
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What is the significance of the kidneys in relation to the cardiovascular system?
What is the significance of the kidneys in relation to the cardiovascular system?
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Which symptom is not typically associated with gastrointestinal issues?
Which symptom is not typically associated with gastrointestinal issues?
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What is a common method used to assess abdominal findings?
What is a common method used to assess abdominal findings?
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In which position should a pregnant female be assessed to ensure comfort and safety?
In which position should a pregnant female be assessed to ensure comfort and safety?
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What does the term 'dysuria' refer to in the context of urinary symptoms?
What does the term 'dysuria' refer to in the context of urinary symptoms?
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What anatomical landmark is typically referred to for locating the appendix?
What anatomical landmark is typically referred to for locating the appendix?
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Which reproductive health concern is specifically related to female patients?
Which reproductive health concern is specifically related to female patients?
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Which of the following is not a method included in physical assessment techniques?
Which of the following is not a method included in physical assessment techniques?
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What is the normal range of bowel sounds heard during auscultation?
What is the normal range of bowel sounds heard during auscultation?
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Which area of the abdomen is typically most active during auscultation?
Which area of the abdomen is typically most active during auscultation?
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What does the presence of shifting dullness during percussion indicate?
What does the presence of shifting dullness during percussion indicate?
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Which percussion technique is used to assess the size of the liver?
Which percussion technique is used to assess the size of the liver?
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During abdominal inspection, what aspect is NOT typically assessed?
During abdominal inspection, what aspect is NOT typically assessed?
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What findings during auscultation may suggest hypertension or narrowing of arteries?
What findings during auscultation may suggest hypertension or narrowing of arteries?
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Which symptom is associated with jaundice during abdominal inspection?
Which symptom is associated with jaundice during abdominal inspection?
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What does the observation of clear and light yellow urine suggest?
What does the observation of clear and light yellow urine suggest?
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What is the expected finding when palpating the vertical nodes from the superior ramus to 5 cm distally?
What is the expected finding when palpating the vertical nodes from the superior ramus to 5 cm distally?
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Which structures should be inspected during a rectal examination?
Which structures should be inspected during a rectal examination?
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What is indicated by rebound tenderness in the context of acute abdomen?
What is indicated by rebound tenderness in the context of acute abdomen?
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What is the purpose of using lots of water-soluble lubrication during a Digital Rectal Exam (DRE)?
What is the purpose of using lots of water-soluble lubrication during a Digital Rectal Exam (DRE)?
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In children, what is the daily fluid requirement for the first 10 kg of body weight?
In children, what is the daily fluid requirement for the first 10 kg of body weight?
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What does a stool characteristic check during a Digital Rectal Exam help to identify?
What does a stool characteristic check during a Digital Rectal Exam help to identify?
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What does adequate water intake depend on for adults?
What does adequate water intake depend on for adults?
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Which procedure is NOT considered a further test for evaluating rectal or abdominal issues?
Which procedure is NOT considered a further test for evaluating rectal or abdominal issues?
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Study Notes
Breast Assessment
- Assessment includes breast areola and nipple size, symmetry, and shape.
- Skin assessment (redness, swelling, ulcers, edema) is also conducted.
- Masses and discharge are also evaluated.
- Gynecomastia is a possible finding.
Breast General Survey, Health History, ROS
- Health history questions relating to breast health include asking about changes or concerns, cyclical or ongoing alterations, and risk factors for breast cancer.
Breast Development
- Thelarche marks the beginning of adult breast development, signaling puberty.
- Age ranges for the start of puberty in different regions vary:
- USA: 8.8-10.3 years
- Asia: 8.9-11.5 years
- Europe: 9.8-10.8 years
- Africa: 10.1-13.2 years
- Average time between Tanner stage 2 and 5 is 4-4.5 years.
Palpate Breasts and Lymphnodes
- Horizontal pattern should be used when palpating across breast tissue.
- Palpation should extend into the axilla for the Tail of Spence.
- Lymphatic assessment should include supraclavicular, interpectoral, infraclavicular, lateral axillary, central axillary, subscapular, pectoral, and parasternal lymph nodes.
Breast Cancer
- Most breast findings are not cancerous.
- Tail of Spence and upper lateral quadrant are the most common locations for cancerous findings among breast cancers.
- Tail of Spence: 5%
- Upper Lateral Quadrant: 25%
- Other areas vary between 10-45% of cancers.
Know Your Body
- Women should understand what normal breast tissue looks and feels like.
- They should regularly check their breasts for changes, including the entire breast area, including under the arms and up to the collar bone, and nipples.
- Consult a doctor promptly if any unusual breast changes are noted, as most changes are not cancer.
Breast Cancer and Men
- Less than 1% of breast cancers occur in men.
- They are often diagnosed at a later stage due to a delay in seeking care.
- In men, breast cancer is frequently detected as lumps in the upper chest, under or near the nipple, or in the armpit.
Red Flags
- Mastitis, an indication of breast infection
- Galactorrhoea, a milky nipple discharge unrelated to breastfeeding
- Gynecomastia
- Persistent discharge in newborns are red flags in breast assessments.
Abdomen & Genitourinary Assessment
- Shared autonomic and somatic (S2-S4) innervation affects bowels and bladder.
- Common symptoms include nausea, vomiting, and diarrhea.
- Abdominal discomfort and distention can be difficult to diagnose, especially in children and elderly patients.
- Pain in specific location of the kidneys, bladder, ureter, prostate, and urethra is useful for diagnostics.
Giddens (2017) Concepts
- Homeostasis and Regulation (Fluid, Electrolytes, Acid-Base balance, Glucose Regulation, Hormonal Regulation, Nutritrion)
- Protection and Movement (Immunity, Inflammation, Infection, Mobility, Tissue Integrity, Sensory Perception, Pain, Sexuality)
- Reproduction and Sexuality
Putting things Together
- Abdominal assessment encompasses multiple body systems.
- Systems involved include neuro, GI, endocrine, hematopoietic/lymphatic, cardiovascular, urinary, and reproductive.
General Survey
- General survey is part of a full physical assessment.
Health History (GI System)
- Assess for pain in relation to the digestive system (nausea, vomiting, dysphagia).
- Evaluate dietary patterns (regurgitation, GERD).
- Assess changes in bowel habits (diarrhea, constipation, flatulence, melena).
- Ask about hemorrhoids and colonoscopies.
- Inquire about family history of conditions such as colon cancer, GERD, IBD, and celiac disease.
- Note patient travel history.
Health History (GU System)
- Assess for urinary tract concerns (frequency, blood, changes; hesitancy, nocturia, incontinence, burning pain, back pain).
- Inquire about medication and contraception use.
- Ask about sexually transmitted infections (STIs) and HPV immunization.
- Evaluate issues relating to female genitalia (menstruation, contraceptive usage, vaginal changes, pregnancy).
- Assess issues relating to male genitalia (pain, trauma, sexual function changes).
Abdominal findings: pain
- Gallbladder pain is often described as crampy and steady pain under the right ribs, often associated with vomiting and fever
- Kidney pain is intermittent and may move from the side to the groin
- Pain from Appendicitis follows a characteristic path: starts around the navel but moves to the lower right side
- Menstrual pain is cramping and occurs at the beginning of a period
- Peptic ulcers present as pain at a precise location below the sternum.
- Excess gas in the digestive tract may lead to bloating and pain.
- Pelvic organ inflammation in women may cause a burning pain across the abdomen.
- Pain originating in the ovaries is localized, deep pain within the pelvis.
Where is the appendix (usually)?
- The appendix is typically located about two-thirds of the way from the umbilicus (belly button) to the anterior superior iliac spine (ASIS).
Landmarking: Quadrants vs. Regions
- The abdominal region is divided into four quadrants and nine regions.
- The right and left upper and lower quadrants are common designations.
- Additional regions include epigastric, umbilical, and hypogastric.
- Regions are helpful for describing pain locations or other abnormalities.
Landmarking: Major Arteries
- Aorta, Renal artery, Iliac artery, and Femoral artery
Landmarking: PNS & MSK
- The image depicts anatomical structures that relate to Peripheral Nervous System and Musculoskeletal System. The image shows major nerves and muscles that are relevant for pain assessment.
Landmarking Genitourinary
- Perineum is diamond shaped area between thighs. The Urogential Triangle contains the urethral and vaginal orifices in females and the base of the penis and scrotum in males. The Anal Triangle incorporates the external sphincter and coccyx.
Physical Assessment: IAPP!
- Physical assessment includes inspection, auscultation, percussion and palpation techniques.
Physical assessment: Abdomen
- Positioning for examination is different for pregnant women (left lateral decubitus position).
- The entire abdomen should be exposed and draped.
- Explain procedures.
Inspection: Expose the abdomen
- RUQ, RLQ, LUQ, LLQ are areas to be assessed for abdominal abnormalities.
Inspection
- Inspect skin tone, visible veins, moisture levels, temperature, texture and the presence of scars
- Evaluate the overall appearance of the abdomen for shape, size, symmetry, bulges, and signs of inflammation or masses.
- Assess the umbilicus for any visible abnormalities or changes.
- Check for clear, light yellow urine, and the presence of soft, bowel-shaped, light browns stool.
Inspection: Skin
- Inspect the skin in the abdominal region for visible changes, colors, visible veins, moisture, temperature, texture, scars, and overall appearance. Assess for symmetry, bulges, or inflammation/masses.
Inspection: Shape/Contour
- Assess the shape and contour of the abdomen in relation to symmetry and level of flatness, scar tissue, or any areas of distension.
Inspection: Hernias
- Abdominal hernias are abnormalities of abdominal musculature that enable abdominal wall contents to protrude through weak points or openings in the muscular wall.
- Umblical, inguinal, and femoral hernias are common.
Inspection: Jaundice Ascites
-
500 mL of extravascular peritoneal fluid.
- Assess for 'shifting dullness' during percussion.
- Fluid wave assessment is also used.
Auscultation: Bowel Sounds
- Assess bowel sounds in all four quadrants, moving in a clockwise direction.
- Normal sounds include clicks, gurgles, and occasionally borborygmi (rumbles).
- Listen for peristaltic sounds occurring 5-30 times per minute across the area.
- Ileocal area is the most active bowel sound site.
Auscultation: Vascular Sounds
- Assess patients for vascular sounds, including bruits, venous hums, hepatic friction rub, and splenic friction rub, in conjunction with palpation.
Percussion
- Percuss the abdomen to assess organ size and tenderness.
- This includes the liver, spleen, kidneys, and the presence of ascites.
Liver percussion
- Standard liver percussion technique involves percussion from the right midclavicular line starting at the 3rd intercostal space where the dullness of the area starts. Move down systematically and note the level where the percussed sound changes from resonant to dull. Normal percussion liver size is 7-10.5 cm for women and men respectively.
- Percuss the area at the umbilicus and then move up following the area with dullness.
Splenic percussion
- Castell's method involves finding the lowest intercostal space on the left anterior axillary line and percussing during expiration and inspiration to check for dullness.
Bladder Percussion (FYI)
- Assess the bladder by percussion from the umbilicus to the pelvic brim.
Kidney percussion
- The kidneys are percussed posteriorly, beginning from the costo-vertebral angle.
- The area is assessed for tenderness.
Light palpation
- Use gentle 1-2cm finger pads to palpate the quadrants, moving in a clockwise direction.
- Note the presence of guarding, masses, and tenderness.
Deep Palpation
- Assess for masses and tenderness with deep palpation. Areas assessed includes Murphy's sign in the RUQ and Rosving's sign to evaluate the region related to Appendicitis.
Anatomical Thinking While Palpating!
- Identify the anatomical structures of the abdomen, including the xiphoid process, liver, gallbladder, kidneys, spleen, stomach, aorta , pancreas, transverse colon , descending colon, sigmoid colon , cecum , and iliac artery. Assess their position, relation to nearby structures and any palpable areas.
Palpation Tips
- Important information for assessing palpation, including bending the knees, palpation on expiration, and the caution or importance of checking if the patient has emptied their bladder before palpation.
Palpation: Inguinal Nodes
- Palpate inguinal nodes systematically (horizontal and vertical).
- Findings include non-tender, slightly palpable nodes (less than 2 cm).
The Rectum & Stool
- Examine the anus for fissures, fistulas, hemorrhoids, tumors, and warts.
- Assess stool characteristics using the Bristol Stool Chart.
Rectum
- Palpation of the rectum involves a digital rectal exam (DRE) with water soluble lubrication, assessing for sphincter tone, stenosis, blood, mucus, polyps, or masses, prostate anatomy, checking the examining finger and stool characteristics.
Further tests
- Additional tests may include blood work (FIT), ultrasound, colonoscopy, CT scan, and MRI.
Red Flag: Acute Abdomen
- Rebound tenderness is a key finding in acute abdomen diagnoses.
- Assess other symptoms like pain in the umbilicus toward the RLQ (McBurney's Point), and the presence of Rovsing sign (deep palpation in LLQ, quick withdraw of this stimuli, elicits rebound tenderness in RLQ)
- Peritonitis, abdominal surgery, ectopic pregnancy, perforations, trauma, or ulcers are also possibilities.
- Additional findings should be taken into account.
Focus on GU
- Assessing the Genitourinary (GU) system focuses on the anatomy and associated pathologies related to the urinary system.
Urine Output/Fluid Balance
- Adequate fluid intake varies by age and activity, with adults needing at least 1500 ml per day. Children need approximately 100ml/kg/24hrs for the first 10 kilos, 50ml/kg/24hrs for the next 10 kilos and 20ml/kg/24hrs for any subsequent kilograms.
Urinary Terminology
- Common urinary terms like frequency, urgency, and dysuria for painfull voiding. -Hesitancy (delay in voiding), nocturnal urination, incontinence (involuntary urination), enuresis (involuntary urination during sleep), polyuria (increased volume of urine), oliguria (decreased urine volume), anuria (no urine production), hematuria (blood in urine), and proteinuria (protein in urine)
Beware of biases
- Avoid biases regarding contraception, sexual function, age and sexually transmitted infections (STIs).
Developmental Aspects
- Tanner stages for male and female puberty development are included in this section.
Physical Assessment
- Procedures to inspect and palpate the genitalia, including the external genitalia and perineum, inguinal lymph nodes, rectovaginal examination and rectal examination. In addition, percussion, as applicable to the assessment of underlying structures (e.g., kidneys) is also discussed.
Inspection: Pelvic Organ Prolapse Example
- Normal anatomy shows the correct position of pelvic organs, while other visual aids present the prolapsed positions of different reproductive organs.
Testicular Exam
- Assess for testicular cancer, self-exams, risk factors (family history, undescended testicle, HIV infection, Caucasian ethnicity)
- Note the high cure rate and avoidance of myths about trauma or physical activity as causes.
Prostate Exam
- Palpate the prostate during a rectal examination in men over 50 years old or those with risk factors, including family history, African ancestry and BRCA gene mutations.
Cervical Cancer Screening
- Cervical cancer screening in Alberta involves Pap tests.
- HPV (Human Papillomavirus) testing may be included for abnormal Pap test results and screening guidelines include start at age 25 years old and continues every three years, up to age 69.
Ovarian Cancer
- Discuss the significant late diagnosis and poorer survival rates for ovarian cancer and the absence of reliable screening tests in reference to the significant symptoms like bloating, difficulty eating, abdominal discomfort and issues with urinary habits that can be overlooked.
- Factors associated with increased risk for developing ovarian cancer (age over 50, family history, and Jewish descent), factors associated with reducing risk (oral contraceptives, full-term pregnancy, tubal ligation).
- Importance of consulting with your doctor to address your specific risk factors and determine appropriate preventative measures is emphasized.
Red Flags
- Sudden onset of testicular pain (torsion), changes in urine stream (prostate issues), ectopic pregnancy (acute abdomen), or symptoms (burning, pain, polyuria) related to a UTI.
- Red flags in older adults, including changes in behavior, call for prompt physician consultation.
Examples of GU Emergencies
- Examples of GU (Genitourinary) emergencies should be prepared for by healthcare professionals.
Penis & Testicles
- Priapism, a persistent erection, and paraphimosis, a foreskin retraction causing edema, are key issues discussed.
- Testicular torsion, a medical emergency causing twisting of the testicle, is also described.
Uterus
- Sudden, severe abdominal or pelvic pain, dizziness, or fainting are signs of a ruptured ectopic pregnancy.
- Pain in the lower back and/or shoulders can also occur in association with such pregnancy complications.
References
- Lists relevant books/references for medical assessments.
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Test your knowledge on the clinical breast exam (CBE) and its importance in breast health assessment. This quiz covers various aspects of breast cancer awareness, including symptoms, risk factors, and assessment techniques. Ideal for those studying healthcare and nursing.
