Download Chapter 16 Breasts and Axillae The breast examination is typically

Chapter 16
Breasts and Axillae
The breast examination is typically performed:
When the patient has a specific breast complaint
As part of an overall annual well person examination
Examination of the breasts includes:
Examination of the axillae
Relevant lymph node chains
Breasts and Axillae (Cont.)
Major focus of the examination in adults is identification of breast masses, skin, or vascular
changes that could indicate malignancy.
In children, it is important for Tanner staging and as part of the evaluation with hormonal
concerns.
Physical Examination Preview
Females
Inspect with patient seated. Compare breasts for:
Size
Symmetry
Contour
Retractions or dimpling
Skin color and texture
Venous patterns
Lesions
Supernumerary nipples
Females (Cont.)
Inspect both areolae and nipples and compare for:
Shape
Symmetry
Color
Smoothness
Size
Nipple inversion, eversion, or retraction
Females (Cont.)
Reinspect breasts with the patient in the following positions:
Arms extended over head or flexed behind the neck
Hands pressed on hips with shoulder rolled forward
Seated and leaning over
Recumbent position
Females (Cont.)
Perform a chest wall sweep.
Perform bimanual digital palpation.
Palpate for lymph nodes in the axilla, down the arm to the elbow, and in the supraclavicular and
infraclavicular areas.
Palpate breast tissue with patient supine, using light, medium, and deep pressure.
Depress the nipple into the well behind the areola.
Males
Inspect breasts for the following:
Symmetry
Enlargement
Surface characteristics
Males (Cont.)
Inspect both areolae and nipples and compare for:
Shape
Symmetry
Color
Smoothness
Size
Nipple inversion, eversion, or retraction
Males (Cont.)
Palpate breasts and over areolae for lumps or nodules.
Palpate for lymph nodes in the axilla, down the arm to the elbow, and in the supraclavicular and
infraclavicular areas.
Anatomy and Physiology
Breasts
Paired mammary glands on anterior chest wall, superficial to the pectoralis major and serratus
anterior muscles
Male breast consists of:
Small nipple and areola
Thin layer of breast tissue
Breasts (Cont.)
Female components
Nipple and areola
Glandular tissue
Fibrous tissue
Subcutaneous fat
Retromammary fat
Breasts (Cont.)
Glandular tissue
Fifteen to 20 lobes per breast radiate about nipple.
Lobes are composed of 20 to 40 lobules.
Lobules consist of milk-producing acini cells.
Lactiferous ducts drain milk from each lobe onto nipple surface.
Breasts (Cont.)
Fibrous tissue
Subcutaneous
Provides breast support
Suspensory ligaments (Cooper ligaments)
Extend from the connective tissue layer through the breast and attach to the
underlying muscle fascia providing further support
Breasts (Cont.)
Muscles forming floor of breast
Pectoralis major and minor
Serratus anterior
Latissimus dorsi
Subscapularis
External oblique
Rectus abdominis
Breasts (Cont.)
Vascular supply
Internal mammary artery
Lateral thoracic artery
Subcutaneous and retromammary fat
Supplies bulk of breast
Varies with age, pregnancy, lactation, and genetics
Breasts (Cont.)
Five segments (for examination purposes): four quadrants and tail
Upper outer quadrant: greatest amount of glandular tissue
Upper inner quadrant
Lower inner quadrant
Lower outer quadrant
Tail of Spence
Breasts (Cont.)
Nipple
Located centrally on the breast and surrounded by the pigmented areola
Epithelium infiltrated with smooth muscle fibers
Lactiferous ducts empty onto nipple
Contraction of the smooth muscle, induced by tactile, sensory, or autonomic stimuli,
produces erection of the nipple and causes the lactiferous ducts to empty
Sebaceous glands (Montgomery tubercles) on areola
Breasts (Cont.)
Lymphatic network
Drains breast radially and deeply to underlying lymphatics
Superficial lymphatics drain skin
Deep lymphatics drain mammary lobules
Complex of axillary lymph nodes
Axillae
Axillary lymph nodes
Anterior axillary (pectoral) nodes
Midaxillary (central) nodes
Posterior axillary (subscapular) nodes
Lateral axillary (brachial) nodes
Children and Adolescents
Breast development
Latent phase in children and preadolescence
Thelarche (breast development) early sign of puberty in adolescent girls
Tanner’s five stages of developing sexual maturity
Breasts develop at different rates in individuals; may result in asymmetry
Tanner’s Five Stages of Breast Development
Tanner 1 (preadolescent)
Only the nipple is raised above the level of the breast, as in the child.
Tanner 2
Budding stage, bud-shaped elevation of the areola
Tanner 3
Breast and areola enlarged
No contour separation
Tanner’s Five Stages of Breast Development (Cont.)
Tanner 4
Increasing fat deposits
Areola forms a secondary elevation above that of the breast.
Occurs in approximately half of all girls and in some cases persists in adulthood
Tanner 5 (adult stage)
Areola is (usually) part of general breast contour and is strongly pigmented.
Nipple projects
Pregnant Women
Lactiferous ducts proliferate.
Alveoli increase in size and number.
Breasts enlarge 2- to 3-fold.
Colostrum is produced.
Areolar pigment increases.
Areolae become more erect.
Vascularization increases.
Lactating Women
Colostrum secreted in the first few days after delivery
More protein and minerals than does mature milk
Contains antibodies and other host resistance factors
Milk produced 2 to 4 days after delivery
Breasts full and tense
Involution period over a period of 3 months after termination of lactation
Older Adults
Decrease in glandular tissue is replaced by fat.
Inframammary ridge thickens.
Breasts hang loosely.
Result of the tissue changes and relaxation of the suspensory ligaments
Nipples are smaller and flatter.
Skin may take on a relatively dry, thin texture.
Hair decreases in axilla.
Review of Related History
History of Present Illness
Breast discomfort
Temporal sequence
Relationship to menses
Character
Associated symptoms
Contributory factors
Medications: nonprescription or hormones
History of Present Illness (Cont.)
Breast mass or lump
Temporal sequence
Symptoms
Changes in lump
Associated symptoms
Medications: nonprescription or hormones
History of Present Illness (Cont.)
Nipple discharge
Character
Associated symptoms
Associated factors
Medications: contraceptives, hormones, phenothiazines, digitalis, diuretics, steroids
History of Present Illness (Cont.)
Breast enlargement in men
History of hyperthyroidism, testicular tumor, Klinefelter syndrome
Medications: cimetidine, omeprazole, spironolactone, finasteride, some
antihypertensives, some antipsychotics
Treatment for prostate cancer: androgens or GnRH analogues
Illicit and/or recreational drugs: anabolic steroids, marijuana
Past Medical History
Previous breast disease: cancer, fibroadenomas, fibrocystic changes
Known BRCA1 or BRCA2 mutation; other known hereditary cancer syndromes
Previous other related cancers: ovarian, colorectal, endometrial
Surgeries: breast biopsies, aspirations, implants, reduction, plasties; oophorectomy
Past Medical History (Cont.)
Changes in breast characteristics: pain, tenderness, lumps, discharge, skin changes, size or
shape changes
Changes in breast occurring with menstrual cycle: tenderness, swelling, pain, enlarged nodes
Risk factors for breast cancer
Mammogram and other breast imaging history: frequency, date of last imaging, results
Past Medical History (Cont.)
Menstrual history: first date of last menstrual period, age at menarche or menopause, cycle
length, duration and amount of flow, regularity, associated breast symptoms (nipple
discharge; pain or discomfort)
Past Medical History (Cont.)
Pregnancy: age at each pregnancy, length of each pregnancy, date of delivery or termination
Lactation: number of children breast-fed; duration of breast-feeding; date of last breast-feeding;
medications to suppress lactation
Past Medical History (Cont.)
Menopause: onset, course, associated problems, residual problems
Use of hormonal medications: name and dosage, reason for use, length of time on hormones,
date of termination
Other nonprescription or prescription medications: tamoxifen, raloxifene
Family History
Breast cancer: primary relatives, secondary relatives; type of cancer; age at time of occurrence;
treatment and results; known BRCA1, BRCA2, or other mutation
Other cancers: ovarian, colorectal known hereditary cancer syndromes
Other breast disease in female and male relatives: type of disease; age at time of occurrence;
treatment and results
Personal and Social History
Age
Breast support used with strenuous exercise or sports activities
Amount of caffeine intake; impact on breast tissue
Breast self-awareness/self-examination: frequency; at what time in the menstrual cycle
Use of alcohol; daily amounts
Use of anabolic steroids or marijuana
Pregnant Women
Sensations: fullness, tingling, tenderness
Presence of colostrum and knowledge about how to care for breasts and nipples during
pregnancy
Use of supportive brassiere
Knowledge and information about breast-feeding
Plans to breastfeed, experience, expectations
Lactating Women
Breast cleaning procedures
Nursing bra
Nipples: tenderness, pain, or related problems
Associated problems
Nursing routine
Lactating Women (Cont.)
Breast milk–pumping device and frequency of use
Cultural beliefs about nursing
Food and environmental agents that affect milk
Medications that cross milk–blood barrier
All medications, prescription and nonprescription, should be evaluated for potential side
effects in the newborn.
Older Adults
Skin irritation under pendulous breasts from tissue-to-tissue contact or from rubbing of brassiere;
treatment
Hormone therapy during or since menopause: name and dosage of medication; duration of
therapy
Examination and Findings
Breast Self-Examination (BSE)
BSE remains an important tool in the detection of breast cancer.
Women should be told about the benefits and limitations of BSE.
Every woman should be familiar with her own breasts and report any breast change to her health
care provider.
Breast Self-Examination (BSE) (Cont.)
The American Cancer Society recommends BSE as an option for women beginning in their 20s.
As you discuss BSE, it would be an appropriate time to review the accepted recommendations for
early breast cancer detection and to discuss the issues related to breast cancer screening.
Inspection
Breasts: with patient seated and arms hanging loosely at the sides―inspect both breasts and
compare the following:
Size, symmetry, and contour
Retractions or dimpling
Skin color and texture
Venous patterns
Lesions
Supernumerary nipples
Peau d’orange Appearance
Peau d’orange appearance indicates edema of the breast caused by blocked lymph drainage.
Inspection (Cont.)
Inspect both areolae and nipples, compare for the following:
Shape
Symmetry
Color
Smoothness
Size
Nipple inversion, eversion, or retraction
Variations in Breast Size and Contour
Inspection (Cont.)
Nipple and areola—The 5 D’s
Discharge
Depression or inversion
Discoloration
Dermatologic changes
Deviation
Inspection (Cont.)
Reinspect breasts in varied positions.
Arms extended over head or flexed behind neck
Hands pressed on hips with shoulder rolled forward
Seated and leaning forward from waist
Palpation
Patient in seated position
Chest wall sweep
Nodes should not be palpable
Palpation (Cont.)
Patient in seated position
Palpation of the axillae and infraclavicular areas
Nodes should not be palpable
Palpation (Cont.)
Patient in seated position
Bimanual digital palpation
Lymph node palpation
Palpation (Cont.)
Patient in supine position
All areas of breast tissue for lumps or nodules
If a breast mass is felt, note characteristics and palpate its dimensions, consistency, and
mobility.
Palpation (Cont.)
Document masses found.
Location
Size and shape
Consistency
Tenderness
Mobility
Borders
Retraction
Palpation (Cont.)
Tail of Spence
Both axillae
Masses
Nipples
Depression into well behind the areola
Discharge (if present)
Note if spontaneous, unilateral, from a single duct
Palpation (Cont.)
Supernumerary Nipples
Palpation (Cont.)
Males
Expect to feel a thin layer of fatty tissue overlying muscle.
Obese men may have a somewhat thicker fatty layer, giving the appearance of breast
enlargement.
Firm disk of glandular tissue can be felt in some men.
Infants
Breasts of many well newborns, male and female, are enlarged for a relatively brief time.
Result of passively transferred maternal estrogen
Small amount of clear or milky white fluid, commonly called “witch’s milk,” is sometimes
expressed.
Breast enlargement usually disappears within 2 weeks, and rarely lasts beyond 3 months of age.
Adolescents
The right and left breasts of the adolescent female may not develop at the same rate.
Reassurance
Breast tissue of the adolescent female feels homogeneous, dense, firm, and elastic.
Start BSE early.
Provides opportunity for reassurance and education
Adolescents (Cont.)
Transient unilateral or bilateral subareolar masses in males
Firm, sometimes tender, and often a source of great concern to the patient and his
parents
Disappear, usually within a year
Gynecomastia in males
Unusual and unexpected enlargement that is readily noticeable
Usually temporary and benign and resolves spontaneously
Pregnant Women
Inspection
Increase in size
Tenderness and tingling
Enlarged erect nipples
Vascular spiders and striae
Palpation
Colostrum
Coarse nodularity of breast tissue
Dilated subcutaneous veins
Lactating Women
Palpate breasts.
Engorgement
Clogged milk ducts
Examine nipples.
Irritation or blisters
Petechiae
Cracking
Older Adults
Inspection
Elongation or flattening
Hanging tissue
Smaller nipple size
Palpation
Fine granular glandular tissue
Thickened inframammary ridge
Fluid-filled cysts
Abnormalities
Breasts
Galactorrhea
Lactation not associated with childbearing
Breasts (Cont.)
Paget disease
Surface manifestation of underlying ductal cancer
Breasts (Cont.)
Mastitis
Inflammation and infection of the breast tissue
Breasts (Cont.)
Gynecomastia
Breast enlargement
in men
Breast Lumps
Fibrocystic changes
Benign fluid-filled cyst formation caused by ductal enlargement
Fibroadenoma
Benign tumors composed of stromal and epithelial elements that represent a hyperplastic
or proliferative process in a single terminal ductal unit
Breast Lumps (Cont.)
Malignant breast tumors
Ductal cancer arises from the epithelial lining of ducts
Lobular cancer originates in the glandular tissue of the lobules
Breast Lumps (Cont.)
Fat necrosis
Benign breast lump that occurs as an inflammatory response to local injury
Nipples and Areolae
Intraductal papillomas and papillomatosis
Benign tumors of the subareolar ducts produce nipple discharge
Duct ectasia
Benign condition of the subareolar ducts that produces nipple discharge
Children
Premature thelarche
Breast enlargement in girls before onset of puberty
Cause unknown
Breasts continue to enlarge slowly throughout childhood until full development reached
during adolescence
Question 1
The greatest amount of glandular tissue of the breast lies in which of the following:
A. Tail of Spence
B. Upper outer quadrant
C. Lower outer quadrant
D. Lower inner quadrant
Question 2
Inspection of the breasts usually begins with the patient in which position?
A. Lateral
B. Sitting
C. Standing
D. Supine
Question 3
The anterior axillary lymph nodes would best be palpated at the:
A. Lateral axillary fold
B. Anterior axillary fold
C. Axilla close to the ribs
D. Posterior axillary fold
Question 4
A peppering of nontender, nonsuppurative Montgomery tubercles is considered to be a:
A. Normal finding
B. Sign of cancer
C. Skin disease
D. Symptom of malnutrition