Safe triangle of chest tube Insertion

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1. Lump
〰〰〰〰〰〰〰〰〰〰〰

Lump Hx:
💠 Introduce, permission, Privacy
💠 Personal Data
💠 Complain/duration
💠 HPI
▪️How Discovered
▪️Onset
▪️Progression
▪️Persistence
▪️Multiplicity
▪️Causes/trauma
▪️associated symptoms
🔸Pain
🔸Fever
🔸Discharge
💠 systemic review
💠 Past medical hx
💠 Family hx
💠 social hx
💠 drug hx


Lump Examination
💠Great, Introduce, Permission, Privacy, Wash
💠Exposure bilateral
______
🟫 Inspection: 6s
🔸Site: measure from bony prominance
🔸Size: 3 dimensions
🔸Shape eg hemispherical, oval
🔸Skin over it
1. scar
2. sinus/️discharge
3. dilated vien/️pulsation
4. discoloration
5. ulceration
🔸Symmetry if multible
🔸Special character
______
🟫 Palpation:
🔸Have pain?
🔸Tenderness
🔸Temperature
______
🔸Surface:
▪️smooth
▪️nodular
▪️lobular
▪️irregular
🔸Consistency:
▪️soft
▪️firm
▪️hard
▪️cystic
👉paget test if very small !
👉signs of molding if soft or cystic
🔸Edge
▪️well define
▪️ill define
▪️slippery (lipoma)
______
If soft or cystic do:
🔸Fluctuation test
🔸Translumination
🔸Pulsatile/expansile
🔸Compressiblity:
re expand again to its original size without any external effects
🔸Reducablility:
re expand again to its original size with cough, straigning or gravity
______
🔸Attached to skin
🔸Attached to underling structure:
▪️first free move
▪️then with muscle acting
▪️In the abdomen elevate the leg if disappear➡️ from viscera
if still appear➡️ subcutanous
▪️in the ganglion it will fix to the tendon so it will move with the movement of the tendon, and it will be fix when extend the wrist
______
🟫Special Tests:
According to the site: Bruit, resonance, etc
🟫 Complete by:
1. Regional LN
2. Near joint
3. General ex

〰〰〰〰〰〰〰〰〰
2. Thyroid
〰〰〰〰〰〰〰〰〰
Thyroid History
💠 Introduce, permission, privacy
💠 Personal data
💠 Complain/duration
💠HPI
🟫History of the lump
How Discovered
Onset
Progression
Multiplicity
Causes/trauma
Associated symptoms
▪️Pain
▪️Fever
▪️Discharge

🟫Pressure Symptoms
Shortness of breath
Discomfort swallowing
Hoarsness

🟫History of metabolic status &systemic review for mets
🔻Non specific:
Increase sweating/dryness
Heat/cold intolerance
Generalize fatigue
Loss of hair
🔻CNS:
Metabolic; nervousness, irritability, Insomnia, proximal myopathy.
Systemic review; Weakness, headage
🔻GIT:
Metabolic; Diarrhea/constipation, weight loss/gain, Increase/decrease appetite.
SR; jaundice, abdominal pain/distension
🔻Cardiorespiratory:
Metabolic; palpitation
SR, chest pain, hemoptysis, cough
🔻Genitourinary:
Menses; stop? regular? amount?
Urine; color, amount, frequency

🟫Eye symptoms
Double vision
Blurred vision
Eye pain
Difficult eye closue

💠Past medical history
Similar condition
Admission
Surgery
Blood transfusion
Radiation
FNA
Asthma, DM, HTN

💠Family history
similar condition
Malignancy

💠Drug history
current
chronic
allergy

💠Social
Smoking
Alcohol
Insurance

Thyroid Examination
💠Great, introduce, permission, privacy, wash
💠General:
well,
sitting,
comfortable,
not agitated,
thin/fat
his/her cloth suitable for room temperature
💠Exposure: from nipple line & above

🟫 Inspection: 6Ss
1⃣Swallowing/tongue protrusion
2⃣Site
3⃣Size
4⃣Shape
5⃣Skin over it
▪️scar
▪sinus/discharge
▪️discoloration
▪️dilated veins/ vesible pulsation
▪️ulcer
6⃣Suprasternal notch

🟫Palpation
From anterior: 4Ts
ask about the pain
Temperature
Tenderness
Trachea
Thrill

From posterior
🔸Tell the pt you want to examine him from posterior!
🔸Relax muscle
🔸Support with one ✋and palpate with the other for:
▪️site
▪️size
▪️shape
__
▪️surface
▪️consistency
▪️edge
__
▪️attachment to skin
▪️attachment to muscle
__
▪️palpate isthmus
▪️Movement with swallowing + Retrosternal extension (palpate the lower edge by your little fingers and ask the pt to swallow)
🔸Lymphnodes
▪️submental
▪️submandibular
▪️pre/post auricular
▪️anterior/posterior cervical
▪️occipital
▪️supra/infra clavicular
🔸Skull for swelling

🟫Percussion
clavicle
sternum (from resonant area)

🟫Ascultation
over the swelling
above the swelling

🟫General examination
🔹Upper limp
moist/dry
cold/hot
palmar erythema
acropathy
Vitiligo
fine tremors
pulse
PB
temp
Proximal myopathy (resist abduction of the arm)

🔹Eye
Passive
1⃣lid retraction: sclera above the iris
2⃣exophthalmos: from behind and above the pt
3⃣chemosis
4⃣loss of lateral eye brows
5⃣periorbital edema or redness
Active
6⃣ophthalmoplegia
7⃣convergnce
8⃣lid lag

🔹Reflexes
🔹pretibial myxedema
🔹cardiovascular ex

Breast Examination
💠Great, introduce, permission, privacy, wash
💠Position:
Inspection➡️sitting
Palpation➡️supine
axilla➡️sitting
or all the procedure at 45°!
💠Exposure:
ideally untill the waist
💠Well, comfortable, lie

🟫Inspection:
from in (nipple) to out (axilla)
◾️Symmetry
◾️Nipple-areola complex (6 Ds +R)
1. Direction
2. Displacement (from nipple line)
3 .Deviation
4. Discharge
5. Distruction
6. Dublication
7. Retraction
◾️Skin:
1. Scar
2. Sinus
3. Discoloration
4. Dilated viens or pulsation
5. Dimpling
6. Peau d'orange
7. Ulcer
8. Vesible lump (4s)
9. Inframammary fold for scar
◾️Axilla
1. Skin tethering
2. Axillary swellings (LN)
3. Arm swelling (LN & lymphedema)

🟫Palpation
👉Ask about the pain
👉Use both hands if large breast
👉Start with normal site,
👉Anticlock,
👉6 areas,
👉Palpate nipple area with the palm!
◾️Tenderness
◾️Temperature
◾️Palpate mass
1. size
2. site,
3. shape,
4. surface
5. consistency,
6. edge,
7. attached to skin
8. attached to underlying structure (ask her to push againt the waist then move the lump)
◾️Press the areola for discharge
◾️Axillary LN + Supra and Infra clavicular joint
👉Your right hand with right hand of the patient & vice vera
👉If palpable comment on:
1. site
2. size
3. shape
4. consistency
5. fixity
6. single or multible
7. molten together
🔸anterior
🔸posterior
🔸lateral
🔸pectoral
🔸apical

🟫Other area to examine
◾️chest for pleural effusion
◾️abdomen for organomegally
and ascitis
◾️back for tenderness
◾️general examination

انضمووووووا 😴 القناة👇👇👇


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