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Physical Examination of the Chest, Lungs, Breast, and Axilla
Sonia Comia, M.D. | Alfredo Guzman, M.D. | Elvic Tengco, M.D.
El
Funny
how sometimes you just find things.
Tracy McConnell, How I Met Your Mother

I.

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III.

IV.
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VII.

VIII.
IX.

X.

Paulo Coelho
TOPIC OUTLINE
Chest and Thorax
A. Thorax
B. Lungs
C. Trachea and Major Bronchi (Tracheobroncial
Tree)
D. The Pleurae
E. Anatomic Landmarks
Breathing
A. Chemical and Neurologic Control of
Respiration
B. Breathing Patterns
The Health History
A. Chest Pain
B. Dyspnea
C. Wheezes
D. Cough
E. Summary
Past Medical History
Family History
Personal & Social History
Examination of the Thorax (Chest) & Lungs
A. Initial Survey of Respiration & the Thorax
B. Inspection
C. Palpation
D. Percussion
E. Auscultation
Summary of Examination: Chest and Lungs
Physical Examination of the Breast and Axillae
A. Female Breast
B. Male Breast
C. Lymphatics
D. Breast Lump or Mass
E. Breast Pain or Discomfort
F. Nipple Discharge
G. Modifiable vs. Non-modifiable Risk Factors
H. Visible Signs of Breast Cancer
I. Summary of Breast Cancer Risk Factors
Examination of the Axilla
A. Common Breast Masses

16 June
2014

THORAX MAPPING
To make vertical locations
1. Count the ribs and interspaces
2. Use the Angle of Louis as a guide
3. Place your finger in the hollow curve of suprasternal notch
4. Move your finger down about 5cm to the horizontal bony ridge
joining the manubrium to the body of the sternum
5. Move your finger laterally and find the adjacent 2nd rib and
costal cartilage
6. Using two fingers, you can walk down the interspaces, one
space at a time, on an oblique line

CHEST AND THORAX

THORAX
A cage of bone, cartilage, and muscle that is capable of
movement as the lungs expand
Borders:
o Anteriorly: sternum, manubrium, xiphoid process
o Laterally: 12 pairs of ribs
o Posteriorly: 12 thoracic vertebrae

Chest abnormalities should be described in 2 dimensions:

o Along the vertical axis
o Around the circumference of the chest

TRANSCRIBED BY: TED, ROBIN, BARNEY, MARSHALL, LILY

THORACIC LANDMARKS
ALONG THE VERTICAL AXIS
11th rib
Cartilaginous tip can usually be felt laterally
12th rib
May be felt posteriorly
Possible starting point for counting ribs and
interspaces
With the fingers of one hand, press in and up
against the lower border of the 12th rib, then
walk up the interspaces or follow a more
oblique line up and around to the front of the
chest
Scapula
Inferior tip lies at the level of the 7th rib or
interspace
Vertebrae
Spinous processes are useful anatomic
landmarks
C7
Vertebra is the most protruding process
when the neck is flexed forward
C7 and T1
Equally prominent
VERTICAL LINES AROUND THE CIRCUMFERENCE OF THE

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Physical Examination
of the Chest, Lungs,
Breast, and Axilla

CHEST
Midsternal
and
Vertebral Lines
Midclavicular
Line
Anterior
and
Posterior Axillary
Lines

Midaxillary Line
Scapular Line

TRACHEA AND MAJOR BRONCHI

(TRACHEOBRONCHIAL TREE)
Tubular system that provides pathway for air to move from the
upper airway to farthest alveoli
Breath sounds over the trachea have a different quality than
breath sounds over the lung parenchyma
10cm-11cm long, and 2cm in diameter
Anterior to the esophagus and posterior to the isthmus of the
thyroid
The trachea bifurcates into its mainstream bronchi at the levels of
the sternal angle anteriorly (level of the carina) and the T4
spinous process posteriorly
o Right bronchus: wider, shorter, and more vertical
o During intubation, the tube will most likely go to the right
bronchus, so you have to pull it a few centimeters to make
sure that it is in the trachea.
Main bronchi are divided into 3 on the right, and 2 on the left

THE PLURAE
Visceral pleura
o Serous membranes that cover the outer surface of each lung
Parietal pleura
o Line the upper rib cage and upper surface of the diaphragm
Pleural space is the potential space between visceral and parietal
pleurae
Three major spaces in the chest
o Right pleural cavity
o Left pleural cavity
o Mediastinum

LUNGS
Paired, but not symmetric
o Right: 3 lobes (upper + middle + lower)
o Left: 2 lobes (upper + lower + lingula)
The lingula of the left upper lobe corresponds to the right middle
lobe
Each lung has a major fissure (oblique) which divides the upper
and lower portions
The right lung has a lesser horizontal fissure
Each lobe consists of blood vessels, lymphatics, nerves, and an
alveolar duct connecting with the alveoli
The anterior exam is mainly for the upper and middle lobes
The posterior exam will cover the upper and lower lobes

Anterior

Posterior

Oblique
(Major)
FIssure

Horizontal
(Minor)
Fissure

BORDERS AND LANDMARKS

LUNGS
Apex rises about 2cm to 4cm above the inner
third of the clavicle
Lower border crosses the 6th rib at the
midclavicular line and the 8th rib at the midaxillary
line
Tipe lies at the level of T1
Anatomic lower border lies at about the level of
T10 spinous process
Ausculatatory lower border lies only up to the 9 th
ICS, which is also the percussion border
FISSURES
Divides each lung roughly in half
May be approximated by a string that runs from
the T3 spinous process obliquely down and
arounf the chest to the 6th rib at the midclavicualr
line
Further divides the right lung
Anteriorly, it runs close to the 4th rib and meets
the oblique fissure in the midaxillary line near the
5th rib

LOCATIONS ON THE CHEST

Supraclavicular above clavicle
Infraclavicular below clavicles
Interscapular between scapulae
Infrascapular below scapular
Bases of the lungs lowermost portions

TRANSCRIBED BY: TED, ROBIN, BARNEY, MARSHALL, LILY

ANATOMIC LANDMARKS
Nipples
Manubriosternal junction (Angle of Louis)
Suprasternal notch
Costal angle
Vertebral prominence
Clavicles

BREATHING
CHEMICAL AND NEUROLOGIC CONTROL OF RESPIRATION
Purpose: to keep the body adequately supplied with O2 and to
protect it from excess CO2
Involves movement of air back and forth from alveoli to outside
(Ventilation)
Gas exchange across the alveolar-pulmonary capillary
membranes (diffusion and perfusion), and circulatory system
transport of O2 to, and CO2 from, the peripheral tissues
Chemoreceptors in the medulla oblongata: sensitive to changes
in [H] ion in the blood and the spinal fluid
Chemoreceptors in the carotid bodies: respond to changes in
arterial O2 and CO2 levels
Both of these receptors respond by sending signals to the
respiratory center in the medulla oblongata
Nerve impulses from here are transmitted ot two subcenters in
the pons, which regulate the respiratory muscles
Excess level of CO2 stimulate the rate and depth of respiration
MUSCLES OF RESPIRATION
DESCRIPTION
Dome-shaped
Primary muscle of inspiration
External Intercostal
Increase
anteroposterior
chest
diameter during inspiration
Internal Intercostal
Decrease
transverse
diameter
during expration
Ribcage
and
neck Expand thorax during inspiration
muscles (parasternals
and scalenes)
Sternocleidomastoid
Contribute to respiratory movements
and trapezius
MUSCLES
Diaphragm

1. During inspiration, as these muscles contract, the thorax expands

2. Intrathoracic pressure decreases, drawing air through the
tracheobronchial tree into the alveoli, or distal air sacs, and
expanding the lungs

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Physical Examination
of the Chest, Lungs,
Breast, and Axilla

3. Oxygen diffuses into the blood of adjacent pulmonary capillaries

while carbon dioxide diffuses from the blood into the alveoli
4. After inspiratory effort stops, the expiratory phase begins
5. The chest wall and lungs recoil, the diaphragm relaxes and rises
passively, air flows outward, and the chest and abdomen return
to their resting positions
During exercise and in certain diseases, extra work is required to
breathe, and accessory muscles join the inspiratory effort
The sternocleidomastoids are the most important of these
muscles.
BREATHING PATTERNS

Find out when the symptom occurs, at rest or with exercise, and
how much effort produces onset.
Carefully elicit the timing and setting of dyspnea, any associated
symptoms, and relieving or aggravating factors
Anxiety may cause episodic dyspnea during both rest and
exercise
10 Ps of Dyspnea
o Pneumonia
o Pneumothorax
o Pulmonary constriction (asthma)
o Peanut (foreign body)
o Pulmonary embolus
o Pericardial tamponade
o Pump failure (heart failure)
o Peak seekers (high altitude)
o Psychogenic
WHEEZES
Musical respiratory sounds that may be audible both to the
patient and to others
Wheezing suggests partial airway obstruction from secretions,
tissue inflammation, or a foreign body
COUGH
Reflex response to stimuli that irritate receptors in the larynx,
trachea, or large bronchi
Ask whether the cough is dry or produces sputum, or phlegm
Ask patient to describe the volume, color, odor, and consistency
of any sputum

THE HEALTH HISTORY

Common or concerning symptoms:
Chest pain
Dyspnea
Wheezes
Cough
Blood-streaked sputum (hemoptysis)

CHEST PAIN
Your initial questions should be as broad as possible. Do you
have any discomfort or unpleasant feelings in your chest?
As you proceed to the full history, ask the patient to point to
where the pain is in the chest
Watch for any gestures as the patient describes the pain
Remember: Lung tissue itself has no pain fibers
Pain in lung conditions such as pneumonia or pulmonary
infarction usually arises from inflammation of the adjacent parietal
pleura
Muscle strain from prolonged recurrent coughing may also be
responsible
The pericardium also has a few pain fibers the pain of
pericarditis stems from inflammation of the adjacent parietal
pleura
Anxiety is the most frequent cause of chest pain in children;
costochondritis is also common
SOURCES OF CHEST PAIN
Angina
pectoris,
myocardial
infarction
Pericardium
Pericarditis
Aorta
Dissecting aortic aneurysm
Trachea and large bronchi Bronchitis
Parietal pleura
Pericarditis, pneumonia
Chest
wall,
including Costochondritis, herpes zoster
musculoskeletal system
and skin
Esophagus
Reflux esophagitits, esophageal
spasm
Extrathoracic structures Cervical arthritis, biliary colic,
such
as
the
neck, gastritis
gallbladder, and stomach
Myocardium

DYSPNEA
A non-painful but uncomfortable awareness of breathing that is
inappropriate to the level of exertion
Ask Have you had any difficulty breathing?

TRANSCRIBED BY: TED, ROBIN, BARNEY, MARSHALL, LILY

COUGH
Dry, hacking cough
Productive cough
Mucoid sputum
Purulent sputum
Foul-smelling sputum
Tenacious sputum
Large
volumes
of
purulent sputum

SIGNIFICANCE
Mycoplasmal pneumonia
Bronchitis,
viral
or
bacterial
pneumonia
Translucent, white, or gray
Yellowish or greenish
Anaerobic lung abscess
Cystic fibrosis
Bronchiectasis or lung abscess

To help parents quantify volume, a multiple-choice question may

be helpful
If possible, ask the patient to cough into a tissue, and then
inspect the phlegm and its characteristics
Hemoptysis is the coughing up of blood from the lungs
It may vary from blood-streaked phlegm to frank blood
Assess the volume of blood produced as well as the other
sputum attributes
Ask about the related setting and activity and any associated
symptoms
Before using the term hemoptysis, try to confirm the source of
the bleeding by both history and physical examination
Blood originating in the stomach is usually darker than blood from
the respiratory tract and may be mixed with food particles
SUMMARY
CHEST PAIN
Onset and Duration: associated with trauma, cough, LRI
Associate Symptoms: shallow breathing, fever, uneven chest
expansion, cough, radiation of pain
Efforts to treat: heat, splinting, medication
DYSPNEA
Onset: sudden or gradual; duration
Pattern: position most comfortable, number of pillows used related
to extent of exercise, certain activities
Severity: extent of activity limitation, fatigue with breathing
Associated symptoms: pain or discomfort, cough, diaphoresis, ankle
edema
COUGH
Onset: sudden, gradual, duration
Nature of cough: dry, moist, wet, hacking, barking, whooping,
bubbling, productive, nonproductive
Sputum production: duration, frequency
Sputum characteristics: amount, color, odor

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Physical Examination
of the Chest, Lungs,
Breast, and Axilla

Pattern: occasional, regular, paroxysmal; related to time of day,

weather, activities
Severity: tires patients, disrupts sleep
Associated symptoms: SOB, chest pain, fever, hoarseness
Efforts to Treat: medications and their effectiveness
PAST MEDICAL HISTORY

Thoracic trauma or surgery, hospitalizations for pulmonary

disorders
Use of Oxygen or ventilation-assisting devices
Chronic pulmonary diseases:
o PTB
o Asthma
o COPD
Other chronic disorders:
o Cardiac
o Cancer
Testing:
o Allergy
o Pulmonary function tests (PFT)
o Tuberculin & fungal skin tests
o Chest x-ray (CXR)

FAMILY HISTORY

Tuberculosis
Emphysema
Allergy, Asthma, Atopic dermatitis
Malignancy
Cystic fibrosis
PERSONAL & SOCIAL HISTORY

Employment: nature of work, environmental hazards, exposure to

chemicals, vapors, dust, pulmonary irritants, use of protective
devices, allergens
Home environment : allergens, air conditioners, humidifiers
Tobacco use: type of tobacco, duration , amount, age started,
efforts to quit, passive smoke
= # # /

Exposure to respiratory infections: influenza, tuberculosis

Nutritional Status: weight loss or obesity
Regional or travel exposures
Hobbies: pigeons or parrots, woodwork, welding
Use of alcohol/illegal drugs
Exercise tolerance
EXAMINATION OF THE THORAX (CHEST) & LUNGS
INITIAL SURVEY OF RESPIRATION & THE THORAX

It is helpful to examine the posterior thorax & lungs while the

patient is sitting and the anterior thorax and lungs with the patient
supine.
Even though you may have already recorded the respiratory rate
when you took the vital signs, it is wise to again observe the rate,
rhythm, depth, and effort of breathing.
A normal resting adult breathes quietly and regularly about 14-20
times a minute.
Assess the patients color for cyanosis and clubbing
o Cyanosis signals hypoxia
o Clubbing of the nails can be observed in patients with chronic
obstructive pulmonary disease (COPD) or congenital heart
disease
Listen to the patients breathing
o Is there any audible wheezing?
o If so, where does it fall in the respiratory cycle?
o Audible stridor, a high-pitched wheeze, is an ominous sign of
airway obstruction in the larynx or trachea.
Inspect the neck
o During inspiration, is there contraction of the SCM or other
accessory muscles, or supraclavicular retraction?
o Is the trachea midline?
o Inspiratory contraction of the SCM at rest signals severe
difficulty breathing.
o Lateral displacement of the trachea in pneumothorax, pleural
effusion, or atelectasis
Observe the shape of the chest

TRANSCRIBED BY: TED, ROBIN, BARNEY, MARSHALL, LILY

o The (AP) diameter may increase with aging and in patients

with COPD
INSPECTION

You have to expose the whole thorax

Patient must remove clothing
From a midline position behind the patient, note the shape of the
chest and the way in which it moves, including:
o Deformities or asymmetry (note the shape & symmetry of the
chest back & front; AP diameter is < Transverse diameter by
half)
o Abnormal retraction of the interspaces during inspiration
(retraction in severe asthma, COPD, or upper airway
obstruction)
o Impaired respiratory movement on one or both sides or a
unilateral lag (or delay) in movement
Condition
Barrel chest

Kyphosis
Scoliosis
Pectus Excavatum
(tunnel chest)

Pectus Carinatum
(pigeon chest)

Observations
Ribs more horizontal, sternal angle more
prominent; trachea displaced posteriorly
AP diameter
Spine deviated POSTERIORLY
Spine deviated LATERALLY
Indentation of the lower sternum above
the xiphoid process
Note depression in the lower portion of
the sternum
Compression of the heart and great
vessels may cause murmurs
Prominent sternal protrusion
AP diameter
Costal cartilages adjacent to the
protruding sternum are depressed

Watch a patient breath and pay particular attention to:

1. General comfort and breathing pattern of the patient.
Do they appear:
o Distressed
o Diaphoretic
o Labored
o Are the breaths regular and deep?
2. Use of accessory muscles of breathing (e.g. scalenes,
sternocleidomastoids) as it signifies some element of respiratory
difficulty.
3. Color of the patient, in particular around the lips and nail beds.
Watch for cyanosis
Watch for clubbing of the fingertips (oo, yung fingertips
nagpaparteeyy!)
CLUBBING Acronym:
o C Cyanotic heart diseases
o L Lung diseases; Hypoxia, Lung cancer, Bronchiectasis,
Cystic fibrosis
o U Ulcerative colitis, Crohns disease
o B Biliary cirrhosis
o B Birth defect (Harmless)
o I Infective Endocarditis
o N Neoplasm (especially Hodgkins lymphoma)
o G GI malabsorption

Clubbing, when fingernails are viewed from side,

angle of base of nail is >160

o Clubbing can be either:

a. Primary
Has a direct cause that is unknown in origin

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Physical Examination
of the Chest, Lungs,
Breast, and Axilla

b. Secondary
A manifestation of an underlying disease
Can be generalized or localized
Generalized
Pulmonary
o Cystic Fibrosis
o Bronchiectasis
Cardiac
o Congenital Cyanotic Heart
Disease
Gastrointestinal
o Crohns Disease
o Ulcerative Colitis
Miscellaneous
o Graves Disease
o Thymoma

Is there any lag or impairment of respiratory movement?

Condition
Normal

Observations
Wider > deep
Lateral diameter > AP diameter

Pectus Excavatum
(Funnel chest)

Depression in the lower portion of

the sternum
Compression of the heart and great
vessels may cause murmurs
Gives chest a somewhat hollowedout appearance.
The x-ray shows a subtle concave
appearance of the lower sternum
Lubog and dibdib mala-funnel

Barrel chest

AP diameter
Normal during infancy
Often accompanies aging and
COPD
Mala-barrel and dibdib aka drum
and tiyan

Pectus Carinatum
(Pigeon Chest)

Anteriorly displaced sternum

AP diameter
Costal cartilages adjacent to the
protruding sternum are depressed
Matulis and dibdib mala-pigeon

Traumatic Flail Chest

Multiple rib fractures may result in

paradoxical movements of the
thorax
As descent of the diaphragm
decreases intrathoracic P, on
inspiration the injured area caves
inward; on expiration, it moves
outward

Thoracic
Kyphoscoliosis

Abnormal spinal curvatures &

vertebral rotation
Kyphosis - spine deviated posteriorly

Localized
Hemiplegia
Trauma

4. The position of the px

Those with extreme pulmonary dysfunction will often sit
upright
In cases of real distress, they assume the Tripod position:
o They will lean forward, resting their hands on their knees

Patient with Emphysema at Tripod Position

5. Breathing through pursed lips, often seen in cases of

emphysema.
6. Ability to speak.
The fewer words per breath, the worse the problem
7. Any audible noises associated with breathing wheezing or
gurgling caused by secretions in large airways are audible
without auscultation.
8. Note any chest or spine deformities (see images at succeeding
text). These may arise as a result of:
Chronic lung disease (e.g. emphysema), congenitally, or
acquired.
In any case, they can impair patient's ability to breath
normally
9. The direction of abdominal wall movement during inspiration.
Normally, the descent of the diaphragm pushes intraabdominal contents down and the wall outward.
Paradoxical breathing
o In cases of severe diaphragmatic flattening (e.g.
emphysema) or paralysis, the abdominal wall may move
inward during inspiration.
o If you suspect this to be the case, place your hand on the
patient's abdomen as they breathe, which should
accentuate its movement.
In respiratory distress, some of the following may occur:
o Accessory muscle use
o Nasal flaring
o Intercostal retractions
o Abdominal paradox
10. Look for prominent chest veins
Especially if the patient also had a raised JVP, as it can occur
due to SVC obstruction
11. Note for scars.
This may give an indication of previous operations or
procedures.
12. Look at the chest wall movements:
Are they symmetrical, i.e. the same on both sides, or
Is there a difference?

TRANSCRIBED BY: TED, ROBIN, BARNEY, MARSHALL, LILY

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Physical Examination
of the Chest, Lungs,
Breast, and Axilla

Scoliosis spine deviated laterally

Kyphosis

o Thyroid Enlargement
o Pleural Effusion
o Tension Pneumothorax
o Tumors
Diaphragm
o Moves downward during inspiration
SCM and Traps (Accessory Muscles)
o prominent in patients with moderate respiratory distress
Tachypnea mild respiratory distress
Shoulder shrugging severe respiratory distress
Smell of breath:
Halitosis significant for abscesses, regurgitation, achalasia
Uremic fetor (smells like urine)
Fruity odor in DKA
Ammoniacal breath in liver disease/failure
MODES OF RESPIRATION

Modes of
Respiration
Thoracic (Costal)
Scoliosis
Others notable chest signs:
Harrisons Sulcus

Depression above costal margin

(from rickets & childhood
asthma)

Use of intercostal muscle

Diaphragmatic

Movement of diaphragm responding

to intrathoracic P

Abdominal

Contraction of diaphragm & interplay

of abdominal muscles resulting to
expansion & recoil of abdominal walls
During labored breathing
Occurs when a negative intrathoracic
P is transmitted to the abdomen by
weakened, poorly functioning
diaphragm, obstructive airways,
during sleep in the event of UAO
o On INSPIRATION: lower thorax is
drawn in & the abdomen
protrudes
o On EXPIRATION: opposite occurs

Paradoxic

Rosary-like formation in Rickets

Rickety Rosary

Observations

DESCRIPTORS OF RESPIRATION

Obstruction at SVC

Obstruction at IVC

Descriptors
of Respiration
Dyspnea

Observations
Difficulty & labored breathing w/
SOB
SOB that begins/ when the px lies
down
Attacks of severe SOB & coughing
that occurs at night, usually awaken
the px from sleep
Dyspnea in the upright posture
Persistent RR > 20/min
Rate slower than 12/min
Breathing laboriously & deeply

Orthopnea
Paroxysmal Nocturnal
Dyspnea

RESPIRATION
POSTERIOR

Px sitting
Arms should be folded across the chest
Hands resting on the opposite shoulders
o Moves the scapulae partly out of the way and increases
access to the lung fields
ANTERIOR

Then ask the px to lie supine and examine the anterior lung fields

Platypnea
Tachypnea
Bradypnea
Hyperpnea
Respiration
Acidosis (metabolic)
CNS lesions (pons)
Anxiety
Aspirin poisoning
Oxygen need
Pain

Respiration
Alkalosis
CNS lesions (cerebrum)
Myasthenia gravis
Narcotic overdose
Obesity (extreme)

INITIAL SURVERY OF RESPIRATION

Rate, rhythm, depth and effort of breathing

Signs of respiratory difficulty
Color
o Pallor deficiency of oxyHb; more associated with anemia
and CV disorders
o Cyanosis excess of deoxyHb; associated with CV but more
often with respiratory disorders
Listen to the Pxs breathing
Inspect the neck
Trachea
Deviates toward the involved side
o Atelectasis
o Significant parenchymal or pleural fibrosis
Deviates toward the opposite side

TRANSCRIBED BY: TED, ROBIN, BARNEY, MARSHALL, LILY

ABNORMALITIES IN RATE & RHYTHM OF BREATHING

PERIODIC BREATHING (CHEYNE-STOKES)

Gradual increases and decreases in respiration with periods of

apnea
Measure the duration of apnea!
ICP, cerebral injury
Regular periodic w/ intervals of apnea followed by a
crescendo/decrescendo sequence of respiration
Children & older adults may breathe in this pattern during sleep
Occurs in patient with brain damage at the cerebral level or w/
drug-caused respiratory compromise
BIOTS RESPIRATION

Rapid, deep respiration (gasps) w/ short pauses between sets

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Physical Examination
of the Chest, Lungs,
Breast, and Axilla

More irregular than Kussmaus

Spinal meningitis, head injury (medullary)
Irregular respiration varying in depth & interrupted by intervals
of apnea but lacking repetitive pattern of Cheyne-Stokes
KUSSMAULS

Tachypnea & hyperpnea

Renal failure, metabolic acidosis, diabetic ketoacidosis
APNEUSTIC

Prolonged inspiratory phase w/ shortened expiratory phase

Lesion in brainstem
SIGHING RESPIRATION

Breathing punctuated by frequent sighs should alert the

possibility of hyperventilation syndrome/ emotional stress;
occasional sighs: normal
OBSTRUCTIVE BREATHING

Expiration is prolonged because of airway resistance

If RR , px lacks sufficient time for full expiration; chest over
expands (air-trapping) & breathing becomes more shallow
PALPATION
Light Palpation

Press in to a depth up to 1cm

Should always precede deep palpation
Deep Palpation
Press in about 4cm
Areas of the Hand to Use in Palpation
Use
To Determine
Palmar surface of fingers
Position
& finger pads
Texture
Size
Consistency
Fluid
Crepitus
Form of a mass structure
Ulnar surface of hand & fingers
Vibration
Dorsal surface of hands

PALPATION
plays a relatively minor role in the examination of the normal
chest as the structure of interest (the lung) is covered by the ribs
and therefore not palpable.
Specific situations where it may be helpful include:
Accentuating normal chest excursion: Place your hands on
the patient's back with thumbs pointed towards the spine.
o Remember to first rub your hands together so that they are
not too cold prior to touching the patient
o Your hands should lift symmetrically outward when the
patient takes a deep breath
o Processes that lead to asymmetric lung expansion, as might
occur when anything fills the pleural space (e.g. air or fluid),
may then be detected as the hand on the affected side will
move outward to a lesser degree.
o There has to be a lot of pleural disease before this
asymmetry can be identified on exam.
1. Thoracic Muscles and Skeleton:
Feel for pulsations, areas of tenderness, bulges, depressions,
unusual movements, and positions
Bilateral symmetry
Elasticity
o Some elasticity rib cage
o Relatively inflexible sternum and xiphoid region
o Rigid thoracic spine

Temperature

Tenderness (*2B 2016)

o If at rib, possible costochondritis
o If at intercostal space, ask px to breathe deeply, (+) is an
indication of lung problem
CHEST EXPANSION

Assess for chest expansion

1. Place your thumbs at the level of the 10th ribs (9th ICS
Doc.Bau), with your fingers loosely grasping and parallel to
the lateral rib cage
2. Position your hands and slide them medially, enough to raise
a loose fold of skin on each side between your thumb and the
spine.
3. Ask the patient to inhale deeply.
4. Watch the distance between your thumbs as they move apart
during inspiration
5. Feel for the range and symmetry of the rib cage as it expands
and contracts

PALPATION IN PHYSICAL EXAMINATION

TRANSCRIBED BY: TED, ROBIN, BARNEY, MARSHALL, LILY

Palpating the front fremitus of the patient

Note the quality of the Tactile Fremitus

o Palpable vibration of the chest wall that results from speech
or other verbalizations, best felt parasternally at the 2nd
intercostal space (ICS), the level of the bifurcation of the
bronchi
1. Use either the ball (the bony part of the palm at the base
of the fingers) or the ulnar surface of your hand to
optimize the vibratory sensitivity
*The bony aspects of the hands are used as they are
particularly sensitive for detecting these vibrations
2. Ask the patient to repeat the words ninety-nine or
one-one-one. This maneuver is repeated until the
entire posterior thorax is covered.
3. If fremitus is faint, ask the patient to speak more loudly or
in a deeper voice
4. Palpate and compare symmetrical areas of the lungs
5. Identify and locate any areas of increased, decreased, or
absent fremitus
*It disappears below the diaphragm
/ Absent Fremitus
excess air
(existing in between the
hand & the lungs)
Emphysema
Pleural effusion
Pleural thickening
Massive pulmonary
Edema
Bronchial obstruction

Fremitus
Fluid/Mass
(solid transmits better than air)
Lung consolidation
Heavy but non-obstructive
secretions
Compressed lungs
Tumor

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Physical Examination
of the Chest, Lungs,
Breast, and Axilla

o or absent fremitus = excess air

The said conditions can collect in the pleural space,
displacing the lung upwards that the fremitus will be
decreased.
o fremitus = presence of fluid/ mass
Alter the transmission of air and sound that the fremitus
becomes more pronounced.

Assess deviation. If deviated, focus ensuing chest exam to

upper lobe problem.
Deviation may be secondary to:
o Atelectasis
o Thyroid enlargement
o Significant parenchymal and/or pleural fibrosis
o Pleural effusion
o Tension pneumothorax
o Tumor or nodal enlargements

Palpating the trachea

Areas to palpate for the front fremitus (Left) & back fremitus (Right)

Diagram for pleural effusion & consolidation

Effusions and infiltrates can perhaps be more easily

understood using a sponge to represent the lung. In this
model (pictured above):
o Infiltrate = blue coloration that has invaded the sponge
itself (left)
o Effusion = blue fluid upon which the lung is floating
(right)
Investigating painful areas: If the patient complains of pain
at a particular site it is important to carefully palpate around
that area. for evidence of
o Rib fracture
o Subcutaneous air (feels like your pushing on Rice
Krispies or bubble paper), etc.
Other conditions which can be detected during physical
examination (palpation/ auscultation):
o Crepitus
Crackly or crinkly sensation (both palpated and
heard; gentle, bubbly feeling
May indicate the presence of air from a subcutaneous
rupture somewhere in the respiratory tract/ lungs, or
infection of a gas forming organism (i.e. bacteria)
o Pleural Friction Rub
Palpable, coarse, grating vibration usually during
inspiration
Caused by inflammation on pleural surfaces (feel of
leather rubbing on leather)
2. Position of the trachea
Palpate the trachea in the supra-sternal notch by either the
index finger or both the index and middle fingers to detect its
position, central or shifted to one side.

TRANSCRIBED BY: TED, ROBIN, BARNEY, MARSHALL, LILY

PERCUSSION
Involves striking one object against another thus producing
vibration & subsequent sound waves
In P.E., finger functions as hammer, vibration is produced by
impact of finger against tissue
Percussion helps you establish whether the underlying tissues
are air-filled, fluid-filled, or solid
Penetrates only 5 7 cm into the chest, however, and will not
help you to detect deep-seated lesions
The degree of percussion tone is determined by the density of
the medium through which sound waves travel
The more dense the medium, the quieter the percussion tone
CLASSIFICATION OF THE DEGREE OF PERCUSSION TONE
TYPE OF TONE
EXAMPLE OF
PATHOLOGIC
LOCATION
EXAMPLE
Flat
Muscle (thigh)
Large Pleural
effusions (flat tone,
decreased fremitus),
atelectasis,
consolidation
Dull
Liver
Lobar pneumonia,
atelectasis, if you are
hitting the tumor itself
Resonant
Normal lung
Simple chronic
bronchitis
Hyperresonance
None normally
Emphysema,
pneumothorax
Tympany
Gastric air bubble
Large pneumothorax
or puffed out cheek
PERCUSSION NOTES AND THEIR CHARACTERISTICS
TYPE OF
INTENSITY
PITCH
DURAQUALITY
TONE
TION
Resonant
Loud
Low
Long
Hollow
Flat
Soft
High
Short
Ext. dull
Dull
Medium
Med-High
Med
Thud-like
Tympanic
Loud
High
Med
Drum-like
HyperVery loud
Very low
Longer
Booming
resonant
HYPERRESONANCE
Abnormal sound in adults
Represents air trapping such as occurs in obstructive lung
diseases. e.g. pneumothorax or asthma
Chronic air trapping in the lung (emphysema) and acute air
trapping in the pleural space (pneumothorax)
Hyperresonance associated with hyperinflation may
indicate:
o Emphysema
o Pneumothorax
o Asthma
DULLNESS OR FLATNESS
Suggests atelectasis, pleural effusion
Suggests air filled tissue displaced by fluid (pleural effusion) or
infiltrated with leukocytes and bacteria (pneumonia) and/or
atelectasis

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Physical Examination
of the Chest, Lungs,
Breast, and Axilla

TECHNIQUES OF PERCUSSION
Immediate (direct) percussion
Involves striking the finger or hand directly against the body
Mediate (indirect) percussion
The finger of one hand acts as the hammer (plexor) & the
finger of the other hand acts as the striking surface
STEPS IN INDIRECT PERCUSSION

1. Place your non-dominant hand on the

surface of the body with the fingers
slightly spread

2. The distal phalanx of the middle

finger placed firmly on the body
surface with the other fingers
slightly elevated off the surface.

3. Snap the wrist of your other hand

downward, & with the tip of the middle
finger sharply tap the IP joint of the
finger that is on the body surface.

Essential Points in Percussion

The downward snap of the striking finger originates from the
wrist & not the forearm or shoulder.
The tap should be sharp and rapid.
The tip and not the pad of the plexor finger is used (hence
SHORT fingernails are required)
LADDER PATTERN FOR PERCUSSION AND AUSCULTATION

Posterior

Anterior

TRANSCRIBED BY: TED, ROBIN, BARNEY, MARSHALL, LILY

Allow hand to swing freely at the wrists, hammering your finger

onto the target at the bottom of the down stroke.
A stiff wrist will NOT elicit a correct sound
If you percuss with your right hand stand a bit to the left side
of your patient
Ask the patient to cross their hands in front of their chest
(grasping the opposite shoulder with each hand): this maneuver
pulls the scapulae laterally, away from the percussion field
Work down the alley that exists between the scapula and the
vertebral column this helps you avoid percussing over bone
Focus on striking the interphalangeal joint (i.e last joint) of your
left middle finger with the tip of the right middle finger.
CUT YOUR NAILS!
The last 2 phalanges of your left middle finger should rest
firmly on your patients back
Try to keep the remainder of your fingers from touching the
patient (IYKWIM), or rest only the tips on them if this is
otherwise too difficult to minimize dampening of the
percussion notes
AUSCULTATION
Involves listening for sounds produced by the body
Requires a stethoscope
Most important examination technique for assessing air flow
through the tracheobronchial tree
Together with percussion, it also helps the clinician assess the
condition of the surrounding lungs and pleural space
Helpful in trying to pin the location of pathologic processes that
may be restricted by anatomic boundaries.
Auscultation involves
o listening to the sounds generated by breathing
o listening for any adventitious (added) sounds
o if abnormalities are suspected, listening to the sounds of the
Pxs spoken or whispered voice as they are transmitted
through the chest wall

BASIC TYPES OF STETHOSCOPE

Acoustic most commonly used
Magnetic
Electronic
Stereophonic

Important Characteristic of a Stethoscope

1. Diaphragm & bell are heavy enough to lie firmly on body
surface
2. Diaphragm cover is rigid
3. Bell is large enough in diameter to span an ICS in an adult &
deep enough so that it will not fill with tissue
4. Rubber or plastic ring around bell edges to ensure secure
contact with body surface
5. Tubing is thick, stiff, & heavy[conducts better]
6. Length: 30.5 - 40 cm [12-18 inches]
7. Earpieces fit snugly & comfortably
8. Angled binaurals point the earpieces toward the nose Involves
striking one object against another thus producing vibration &
subsequent sound waves.
TECHNIQUES IN AUSCULTATION
*from Bates
Listen to the breath sounds with the diaphragm of a stethoscope
after instructing the patient to breathe deeply
Use the pattern for percussion, moving from one side to the
other and comparing symmetric areas of the lungs
If you hear or suspect abnormal sounds, auscultate adjacent
areas so that you can fully describe the extent of any
abnormality
Listen to at least one full breath in each location. Note the
intensity of the breath sounds
Breath sounds are usually louder in the lower posterior lung
fields and may also vary from area to area
If the breath sounds seem faint, ask the patient to breathe more
deeply; you may then hear them easily
1. Put on your stethoscope so that the earpieces are directed away
from you (Dapat hindi tumama sa mata)
Adjust the head of the scope so that the diaphragm is
engaged

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Physical Examination
of the Chest, Lungs,
Breast, and Axilla

If youre not sure, scratch the diaphragm lightly, which should

produce a noise
If not, twist the head and try again (aray!). Gently rub the
head on your shirt so that its not too cold prior to placingit on
the patients skin (ohoho!)
2. The upper aspect of the posterior field (top of the patients
back) are examined first
Listen over to one spot then move the stethoscope to the
same position on the opposite side and repeat. The otherlung
will serve as a comparison for the other (similar to what is
done in percussion)
The entire posterior chest can be covered by listening in
roughly 4 places on each side
When you hear something abnormal, youll need to listen in
more places (particularly regions adjacent/near the region
with abnormal sound)
3. The lingual and right middle lobes can be examined while you
are standing behind the patient
4. Then, move around to the front and listen to the anterior fields in
the same fashion. This is generally done while the patient is still
sitting upright.
Asking female patients to lie down this will allow their breasts
to fall away laterally, which may make this part of the
examination easier.

A healthy individual breathing through their mouth at normal tidal

volumes produces vesicular breath sounds
o Inspiratory component seems to arise in the lung periphery
o Expiratory component arises in the more proximal larger
airways
o Detecting differences in pitch and intensity is often easier
during expiration
Turbulent air flow in the central airways produces the tracheal
and bronchial breath sounds
If bronchovesicular or bronchial breath sounds are heard in
locations distant from those listed, suspect that air-filled lung has
been replaced by fluid-filled or solid lung tissue

ADVENTITIOUS (ADDED) SOUNDS

Detection of adventitious sounds crackles (sometimes called
rales), wheezes, and rhonchi is an important part of your
examination, often leading to diagnosis of cardiac and
pulmonary conditions

Additional Notes
1. Ask the patient to take slow, deep breaths through their mouths
while you are performing your exam.
This forces the patient to move greater volumes of air with
each breath, increasing the duration, intensity, and
detectability of any abnormal breath sounds that might be
present.
2. Have the patient cough a few times prior to auscultation.
o This clears airway secretions and opens small atelectatic
areas at the lung bases
o If the patient cannot sit up, auscultation can be performed
while the patient is lying on their side.
o Get help if the patient is unable to move on their own
o In cases where even this cannot be accomplished, a minimal
examination can be performed by listening laterally/posteriorly
as the patient remains supine
3. Requesting that the patient exhale forcibly will occasionally
help accentuate abnormal breath sounds (e.g. wheezing) that
might not be heard at normal flow rates.
BREATH SOUNDS
Made by the flow of air through the respiratory tree;
characterized by pitch, intensity, duration of inspiratory &
expiratory phases
Classified as:
o Vesicular
o Bronchovesicular
o Bronchial (tubular)

1. Crackles
Abnormal respiratory sound heard more often during
inspiration; characterized by discrete discontinuous sounds,
each lasting just few milliseconds
Caused by disruptive passage of air through the small
airways in the respiratory tree
May be fine, high-pitched (sibilant) or coarse, low pitched
(sonorous)
Characteristics:
o loudness, pitch and duration (summarized as fine or coarse)
o number (few to many)
o timing in the respiratory cycle
o characteristic from breath to breath
Crackles may be heard in some normal people at the anterior
lung bases after maximal expiration
Crackles in dependent portions of the lungs may occur after
prolonged recumbency
Persistence of their pattern from breath to breath
Fine late inspiratory crackles that persist from breath to breath
suggest abnormal lung tissue
Any change after a cough or change in the patients position
Clearing of crackles, wheezes, or ronchi after coughing or
position change suggests inspissated secretions, seen in
bronchitis or atelectasis.
Crackles may result from:
A series of tiny explosions when small airways, deflated
during expiration, pop open during inspiration
From air bubbles flowing through secretions or lightly closed
airways during respiration
2. Wheeze
A continuous, high pitched musical sound, almost a whistle,
heard during inspiration or expiration
Caused by a relatively high velocity air flow through a narrowed
airway

TRANSCRIBED BY: TED, ROBIN, BARNEY, MARSHALL, LILY

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Physical Examination
of the Chest, Lungs,
Breast, and Axilla

3. Rhonchi
Deeper, more rumbling, more pronounced during expiration,
more likely to be prolonged and continuous and less discrete than
crackles
Passage of air through an airway obstructed by thick secretions,
muscular spasm, new growth, or external pressure
In general: rhonchi tend to disappear after coughing, whereas
crackles do not

ADVENTITIOUS
DESCRIPTION
CAUSES
SOUNDS
DISCONTINUOUS intermittent; non-musical
Fine crackles (Rales
Soft, high-pitched,
Pneumonia,
crepitants)
very brief (short
fibrosis, CHF
duration
Coarse crackles
Louder, low-pitched,
Bronchitis,
(Rales bulleux)
not so brief (long
Bronchiectasis
duration
CONTINUOUS longer than crackles; musical
Wheezes
High-pitched, hissing
Asthma,
(Rales sibilants)
or shrill quality
COPD,
bronchitis
Rhoncus
Low-pitched, snoring
Secretions in
(Rales ronflants)
quality
large airways
4. Friction Rub
Occurs outside the respiratory tree dry, crackly, grating, lowpitched sound heard in both expiration and inspiration with
machine-like quality
5. Stridor
Loud, harsh musical breathing sound that unlike the wheezes of
bronchial origin is chiefly inspiratory
Suggests partial obstruction of the larynx or trachea
6. Mediastinal Crunch (Hammans sign)
Found with mediastinal emphysema (pneumomediastinum)
Great variety of noise - loud crackles, clicking and gurgling
sounds
Synchronous with the heartbeat and not with respiration
Easiest to hear when the Px leans to the left (left lateral position)
7. Pleural Effusion
Auscultation over a pleural effusion will produce a very muffled
sound. If, however, you listen carefully to the region on top of the
effusion, you may hear sounds suggestive of consolidation,
originating from lung which is compressed by the fluid pushing up
from below
Asymmetric effusions are probably easier to detect as they will
produce different findings on examination of either side of the
chest.

8. Severe, Stable, Emphysema

Auscultation of patients with severe, stable emphysema will
produce very little sound
Patients suffer from significant lung destruction and air trapping,
resulting in their breathing at small tidal volumes that generate
almost no noise.
Wheezing occurs when there is a superimposed acute
inflammatory process

Greater clarity & increased loudness of spoken words

o suggests that air-filled lung has become airless
2. EGOPHONY
Ask the patient to say ee.
You will normally hear a muffled long E sound
When ee is heard as ay, an E-to-A change (egophony)
is present, as in lobar consolidation from pneumonia
Intensity of spoken voice is increased
Quality sounds nasal (es become stuffy broad as)
3. WHISPERED PETRILOQUY
Ask the patient to whisper ninety-nine or one-twothree.
The whispered voice is normally heard faintly and
indistinctly, if at all.
Louder, clearer whispered sounds are called whispered
pectoriloquy.
SUMMARY OF EXAMINATION: CHEST AND LUNGS
1. Inspect the chest , front & back, noting thoracic landmarks
size & shape (AP diameter compared with transverse)
symmetry
color
superficial venous patterns
prominence of ribs
2. Evaluate respirations for the following:
rate
rhythm or pattern
3. Inspect chest movement with breathing for the following:
symmetry
bulging
use of accessory muscles
4. Note any audible sounds with respirations
e.g. stridor ,wheezes, etc.
5. Palpate the chest for the following:
symmetry
thoracic expansion
pulsations
sensations such as crepitus, grating vibrations
tactile fremitus
6. Perform direct or indirect percussion on the chest,
comparing sides for:
intensity
pitch
duration
quality
7. Auscultate the chest comparing sides for the following:
intensity, pitch, duration and quality of expected breath
sounds
unexpected breath sounds (crackles, rhonchi, wheezes,
friction rubs)
vocal resonance

PHYSICAL EXAMINATION OF BREAST AND AXILLAE*

FEMALE BREAST
* Lifted from Bates

TRANSMITTED VOICE SOUNDS (VOCAL RESONANCE)

If you hear abnormally located broncho-vesicular or
bronchial breath sounds (as in pneumonia), continue on to
assess transmitted voice sounds
With a stethoscope, listen in symmetric areas over the chest
wall as you assess for bronchophony, egophony, and
whispered petriloquy
Increased transmission of voice sounds air-filled lung has
become airless.
1. BRONCHOPHONY
Ask patient to say ninety-nine.
Normally, the sounds transmitted through chest wall are
muffled and indistinct

TRANSCRIBED BY: TED, ROBIN, BARNEY, MARSHALL, LILY

Paired mammary gland that lies against the anterior thoracic wall

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Physical Examination
of the Chest, Lungs,
Breast, and Axilla

Extends:
o from the clavicle and the 2nd rib down to the 6th rib, and
o from the sternal margin across to the midaxillary line
Its surface area is generally rectangular rather than round
Overlies the pectoralis major and, at its inferior margin, the
serratus anterior
Muscles forming the floor of the breast:
o pectoralis major/minor
o serratus anterior
o latissimus dorsi
o subscapularis
o external oblique
o rectus abdominis
Blood supply: internal mammary/lateral thoracic
Composed of secretory tubuloalveolar glands and ducts that
forms 15 to 20 lobes radiating around the nipple
Within each lobe are many smaller lobules that drain into milkproducing ducts and sinuses that open onto the surface of the
areola, or nipple
Fibrous connective tissue
o Provides structural support in the form of fibrous bands or
suspensory ligaments connected to both the skin and the
underlying fascia
Adipose tissue/fat
o Surrounds the breast, predominantly in the superficial and
peripheral area
o Proportions of these components vary with:
Age
General state of nutrition
Pregnancy
Exogenous hormone use
Supernumerary nipples
o Extra nipples located along the milk line, and only a small
nipple and areola are usually present, often mistaken for a
common mole
o there may be underlying glandular tissue
o No pathologic significance
Five Segments of the Breast:
o Based on horizontal and vertical lines crossing the nipple:
Upper Outer Quadrant greatest amount of glandular
tissue
Lower Outer Quadrant
Upper Inner Quadrant
Lower Inner Quadrant
Tail of Spence- extends toward the anterior axillary fold

LYMPHATICS

LYMPH NODE
Pectoral nodes
(Anterior)

Subscapular
nodes (Posterior)

Lateral nodes
Central axillary
nodes

Infraclavicular
nodes

Supraclavicular
nodes

LOCATION
Lower border of the
pectoralis major
inside the anterior
axillary fold
Lateral border of the
scapula,
palpated deep in the
posterior axillary fold
Upper humerus
Midway between the
anterior and
posterior axillary
folds
Below the clavicle
*not strictly axillary
nodes, located
outside the axilla
Above the clavicle

DRAINAGE
Anterior chest wall
and much of the
breast
Posterior chest
wall and a portion
of the arm
Most of the arm
Channels from
central axillary
nodes
Channels from the
central axillary
nodes
Channels from
central axillary
nodes

*Snell, 9th ed
Central nodes are palpable most frequently
Lymph drains from the central axillary nodes to the infraclavicular
and supraclavicular nodes
Not all lymphatics of the breast drain into the axilla
Malignant cells from a breast CA may spread directly to the
infraclavicular nodes into deep channels within the chest
HEALTH HISTORY
Common or concerning symptoms:
o Breast lump or mass
o Breast pain or discomfort
o Nipple discharge
BREAST LUMP OR MASS
Lumps may be physiologic or pathologic, ranging from cysts and
fibroadenomas to breast CA
Temporal sequence

Nipple and areola

o Both are well supplied with smooth muscle that contracts to
express milk from the ductal system during breast-feeding
o Rich sensory innervations (esp. in the nipple) triggers milk
letdown following neurohormonal stimulation from infant
sucking
o Tactile stimulation of the area, including the breast
examination, makes the nipple smaller, firmer, and more
erect, while the areola puckers and wrinkles (these normal
smooth muscle reflexes should not be mistaken for signs of
breast disease)

Symptoms

Changes in lump

Associated symptoms

length of time since lump first

noted
tenderness
pain
dimpling
change in color
size
character
relationship to menses
nipple discharge
tender lymph nodes
Medications

MALE BREAST
Consists of a small nipple and areola
Overlie a thin disc of undeveloped breast tissue

TRANSCRIBED BY: TED, ROBIN, BARNEY, MARSHALL, LILY

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Physical Examination
of the Chest, Lungs,
Breast, and Axilla

BREAST PAIN OR DISCOMFORT

Temporal sequence

Relationship to Menses
Character

Associated symptoms
Contributory factors
Efforts to Treat

length of time since lump first

noted
sudden or gradual
duration

pulling
throbbing
burning
stabbing
nipple discharge
Lumps/Mass
skin irritation
recent injury to breast
Medications

NIPPLE DISCHARGE
Does the discharge appear only after compression of the nipple,
or is it spontaneous?
o If it appears only after squeezing the nipple, it is considered
physiologic
Physiologic hypersecretion: pregnancy, lactation, chest
wall stimulation, sleep, and stress
o If spontaneous:
what is the color, consistency, and quantity?
Is the color milky, brown or greenish, or bloody?
Ask if the discharge is unilateral or bilateral
Galactorrhea is the inappropriate discharge of milk-containg
fluid. If it occurs 6 or more months after child birth or cessation of
breast-feeding it is ABNORMAL.
A nonmilky unilateral discharge suggests local breast disease
PAST MEDICAL HISTORY
Menstrual history menarche/menopause
Pregnancy
Lactation
Surgeries: biopsies, aspirations, implants
Previous breast disease: cancer, fibroadenomas, fibrocystic
disease
Use of hormonal medications

FAMILY HISTORY
Positive Family History - First-degree relatives, namely a
mother or sister with breast cancer
Having first-degree relatives with breast cancer who are
premenopausal with bilateral dis-ease confers the highest risk.
MODIFIABLE VS. NON-MODIFIABLE RISK FACTORS
There are modifiable and non-modifiable factors that increase the
risk of having breast cancer
Non-modifiable: age, family history, age at first full-term
pregnancy, early menarche, late menopause, breast density etc.
Modifiable: postmenopausal obesity, use of HRT, alcohol use,
physical inactivity etc.

Skin Dimpling
Look for this sign with the
patients arm at rest, during
special positioning, and on
moving or compressing the
breast

Edema of the Skin

Edema of the skin is
produced
by
lymphatic
blockade.
Appears as thickened skin
with enlarged poresthe socalled
peau
dorange
(orange peel) sign.
Often seen first in the lower
portion of the breast or
areola.
Abnormal Contours
Look for any variation in the
normal convexity of each
breast, and compare one
side with the other.
Special positioning may
again be useful. Shown here
is marked flattening of the
lower outer quadrant of the
left breast.
Nipple
Retraction
and
Deviation
A
retracted
nipple
is
flattened or pulled inward.
It may also be broadened,
and feels thickened.
When involvement is radially
asymmetric, the nipple may
deviate, e.g. point in a
different direction from its
normal counterpart, typically
toward
the
underlying
cancer.
Pagets Disease of the Nipple
This is an uncommon form
of breast cancer that usually
starts as a scaly, eczema
like lesion.
The skin may also weep,
crust, or erode.
A breast mass may be
present.
Suspect Pagets disease in
any persisting dermatitis of
the nipple and areola

VISIBLE SIGNS OF BREAST CANCER

Retraction Signs
As breast cancer advances,
it causes fibrosis (scar
tissue).
Shortening of this fibrotic
tissue produces retraction
signs, including:
o Dimpling
o changes in contour
o retraction or deviation of
the nipple.
Other causes of retraction
include:
o fat necrosis
o mammary duct ectasia.

TRANSCRIBED BY: TED, ROBIN, BARNEY, MARSHALL, LILY

EXAMINATION OF THE BREAST

INSPECTION
MALE BREAST
Brief but just as important
If breast appears enlarged, distinguish between the soft fatty
enlargement of obesity and the firm glandular enlargement of
gynecomastia
Inspect nipple and areola
Nodules
Swelling
Ulceration

Inspect skin of each axilla

Rash
Infection
Unusual pigmentation

FEMALE BREAST
Inspect breasts while patient is at sitting position and disrobed to
the waist
Inspect for the following:
o Size, shape, location

Page 13 of 16

Physical Examination
of the Chest, Lungs,
Breast, and Axilla

o
o
o
o

Skin changes
Symmetry
Contour
Retraction in 4 views: arms at sides, arms over head, arms
pressed against hips, and leaning forward

VIEW
ARMS AT SIDES

ARMS OVER
HEAD

ARMS PRESSED
AGAINST HIPS

LEANING
FORWARD

NOTE
Appearance of skin
including:
Color
Thickening
Unusually
prominent pores
Size and
symmetry
Contour (masses,
dimpling, or
flattening)
Nipple charac.
(size, shape,
direction, rashes or
ulceration,
discharge)
A mass in the
pectoralis fascia
leads to contour
changes
Px to raise her
arms over her
head
View contour
changes

This position
allows tension of
pectoralis major
muscle
Examiner moves
the mass to
determine fixation to
the underlying fascia

If the Px have
large and
pendulous
breasts
Retraction and
masses become
more evident

FINDINGS
Redness from
infection or
inflammation
carcinoma
Thickened and
prominent pores
suggest breast
cancer (Peau d
Orange)
Flattening of normally
convex breasts and
asymmetry in which
nipples point suggest
cancer
Recent or fixed
flattening of nipple
suggest retraction
Prominent findings in
this position:
Dimpling or
retraction that
suggest cancer

ccasionally
associated with
benign lesions (i.e.
posttraumatic fat
necrosis, or
mammary duct ectasia)
More prominent in this
position:
lumps that suggest
cancer

o Retraction of nipple
and areola suggest
underlying cancer
o More prominent in
this position:
1. breast assymetry

PALPATION OF THE BREAST

Use the pads of index, middle, ring fingers during palpation. If
open sores or discharge are visible, wear gloves.
Press the breast tissue against the chest wall in small circular
motions. Use very light pressure to assess superficial layer,
moderate pressure for middle layer and firm pressure for deep
layers.
TECHNIQUES IN PALPATING THE BREASTS
Vertical Strip Pattern
Currently the best
validated technique for
detecting breast masses.

Concentric Circles
2nd most used technique

Wedge
Least commonly used

Palpate systematically all 4 quadrants including the tail of

Spence; feel for the lumps and nodules.
a. To examine the lateral portion of the breast (using the vertical
strip pattern):

Ask the patient to roll onto the opposite hip, placing her
hand on her forehead but keeping shoulders pressed
against the bed. This flattens the lateral breast tissue.
Begin palpation in the axilla, moving in a straight line down
to the bra line, then move the fingers medially and palpate
in a vertical strip up the chest to the clavicle.
Continue in vertical overlapping strips until you reach the
nipple, and then reposition the patient to flatten the
medial portion of the breast.
b. To examine the medial portion of the breast (using the vertical
strip pattern)

PALPATION
PATIENT PREPARATION
1. Have the patient lie supine on the exam table.
Palpation is best performed when the breast tissue is
flattened.Therefore, the patient should be supine.
2. Ask the patient to remove the gown from one breast.
Ask the patient to lie with her shoulders flat against the
bed, placing her hand at her neck and lifting her elbow
until it is even with her shoulder. This position allows the
medial part of the breast to be examined better.
Palpate in a straight line, down from the nipple to the bra
line then back to the clavicle, continuing in vertical
overlapping strips to the mid-sternum.

TRANSCRIBED BY: TED, ROBIN, BARNEY, MARSHALL, LILY

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Physical Examination
of the Chest, Lungs,
Breast, and Axilla

PALPATION OF THE NIPPLES

The nipples should be palpated both in males and females.
1. Press it gently between the thumb and index finger.
2. Make note of any discharge. If discharge appears, note the
color and characteristics.
o Milky
o Multicoloured sticky
o Purulent
o Watery
o Serous
o Serosanguinous
3. Have the patient replace the gown and repeat on the other
side.
NIPPLE
Homogenous color and
matches that of the areola
Mostly everted but one or
both nipples may be inverted
Recent unilateral inversion
or retraction of a previously
everted nipple may be a sign
of malignancy
Retraction-flattening,
withdrawal, or inversion of
nipple: indicates pulling by
inflammatory or malignant
tissue

AREOLA
Round or oval
Bilaterally equal or nearly
equal
Color pink to black
May have hair

SUMMARY OF BREAST CANCER RISK FACTORS

FACTOR
RELATIVE RISK
FAMILY HISTORY
First degree relative with breast cancer
1.2 3.0
(mother or daughter)
Premenopausal
3.1
Premenopausal and bilateral
8.5 9.0
Postmenopausal
1.5
Postmenopausal and bilateral
4.0 5.4
MENSTRUAL HISTORY
Age at menarche <12
Age at menopause >55

1.3
1.5 2.0

PREGNANCY
First live birth age 25-29
First live birth after 30
First live birth after 35
Nulliparous

1.5
1.9
2.0 3.0
3.0

BREAST CONDITIONS AND DISEASE

Nonproliferative disease
Proliferative disease
Proliferative with atypical hyperplasia
Lobular carcinoma in situ

1.0
1.9
4.4
6.9 12.0

EXAMINATION OF THE AXILLA

Although the axillae may be examined with the patient lying down,
a sitting position is preferable.

INSPECTION
Inspect the skin of each axilla, noting evidence of:
o Rash
o Infection
o Unusual pigmentation
PALPATION
1. To examine the left axilla, ask the patient to relax with the left arm
down. Help by supporting the left wrist or hand with your left
hand.
2. Cup together the fingers of your right hand and reach as high as
you can toward the apex of the axilla.
3. Warn the patient that this may feel uncomfortable. Your fingers
should lie directly behind the pectoral muscles, pointing toward
the midclavicle.
4. Now press your fingers in toward the chest wall and slide them
downward, trying to feel the central nodes against the chest wall.
Of the axillary nodes, these are the most often palpable. One or
more soft, small (<1 cm), non-tender nodes are frequently felt.
5. Use your left hand to examine the right axilla. If the central nodes
feel large, hard, or tender, or if there is a suspicious lesion in the
drainage areas for the axillary nodes, feel for the other groups of
axillary lymph nodes:
Pectoral nodes
o Grasp the anterior axillary fold between your thumb and
fingers, and with your fingers palpate inside the border of
the pectoral muscle.
Lateral nodes
o from high in the axilla, feel along the upper humerus
Subscapular nodes
o step behind the patient and with your fingers feel inside
themuscle of the posterior axillary fold
6. Also, feel for infraclavicular nodes and reexamine the
supraclavicular nodes.
PALPATION OF THE LYMPH NODES
Palpate the lymph nodes both in male and female patients.
Nodes are NOT usually palpable in adults.
1. Let the patient sit with arms flexed at the elbow.
2. Use palmar surface of the fingers.
3. Reach deeply into the axillary hollow, pushing firmly but not
too aggressively upward then downward.
4. Be sure to explore all sections of the axilla.

Location
Size
Shape
Consistency
Tenderness
Mobility
Borders
Retractions

Breast

Nipple/Areola
Lymph Nodes

TRANSCRIBED BY: TED, ROBIN, BARNEY, MARSHALL, LILY

DOCUMENTING BREAST MASSES

Quadrant, distance from nipple
In cm: length, width, thickness
Round, cystic, discoid, lobular, stellate, regular,
or irregular
Firm, soft, hard
To what degree
Movable or fixed
Discrete or poorly defined
Presence or absence of dimpling; altered
contour
SAMPLE DOCUMENTATION
Moderate size, conical shaped; left slightly
larger than right; granular consistency
bilaterally; 1cm x 2cm x 3cm round mass with
well-delineated borders at the left upper outer,
tender, freely mobile in all directions, soft, no
dimpling/retraction
Left nipple everted, right inverted (lifetime
history); no discharge; areolar dark brown
No supraclavicular or axillar nodes palpable

Page 15 of 16

Physical Examination
of the Chest, Lungs,
Breast, and Axilla

FIBROADENOMA

Usual Age

COMMON BREAST MASSES

CYSTS

Number

15-25, usually puberty and young

adulthood, but up to age 55
Usually single, may be multiple

30-50, regress after menopause

except with estrogen therapy
Single or multiple

Shape
Consistency
Delimitation

Round, disc-like, lobular

May be soft, usually firm
Well delineated

Round
Soft to firm, usually elastic
Well delineated

Mobility

Very mobile

Mobile

Tenderness
Retractions

Usually non-tender
Absent

Often tender
Absent

TRANSCRIBED BY: LUKE, LEIA, HAN, CHEWBACCA

CANCER

30-90, most common over age 50

Usually single, although may
coexist with other nodules
Irregular or stellate
Firm or hard
Not
clearly
delineated
from
surrounding tissues
May be fixed to skin or underlying
tissues
Usually non-tender
May be present

Page 16 of 16