Download 9/30/98 - RollaNet

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9/30/98
PHYS DX
Breast exam
 Why perform
 Part of complete physical
 Mass
 Pain
 Nipple discharge
 Risk factors
 Most common cancer in women
 18% occur in ages 40-49
 1993—180,000 cases  46,000 deaths
 Now—200,000 cases  ~48,000 deaths
 Important to do self exams---7-10 days after onset of menses
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Mass—questions
 When did you first notice?
 Any changes with menses?
 Tender?
 Any skin changes?
 Any recent injuries?
Pts might ask you questions about breast exams and how to do them
Comp boards--Questions on how to do a breast exam or how to tell a woman how to do one
Majority of women who get breast cancer do not have a family history of breast cancer
Family history greatly increases your risk
 mother, daughter  2x  risk postmenopausal
 premenopausal  4x
 both breasts (post)  6x
 both breast (pre)  12x
In 1983 most women sought medical care due to nipple discharge not the mass
76%--discrete mass
5%--pain
6%--nipple discharge/retraction/crusting
8%--swelling of surrounding areas (ex: axilla)
Breast cancer can metastasize
Today mass causes most women to seek care
Questions
 do you do self-screenings?
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PHYS DX
Any other gynecological problems?
Changes?
Note—most women have fibrocystic (benign) changes beginning in their 20’s
(Multiple cysts that vary in size with hormonal changes)
Ovulation  hormones rise  fluid retention, etc.
 Most neoplasias are not tender unless they are in a duct/gland
 Pain is usually due to benign fibrous changes
 Interductal papillomas get tender later but don’t metastasize as quickly, so still chance to catch it
Paget’s disease—nipple area—areola changes
Nipple discharge,
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Intraductal carcinoma
retraction, deviation
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adhesions between tumor and surrounding tissues
Pain—questions—OPPQRST
 Describe the pain (achy, sharp,….)
 Unilateral or bilateral
 Associated symptoms (ex: underarm swelling)
 Recent injury
 Intraductal carcinoma—later stages—can be sharp pain
 Fibrocystic changes—more tender or tense—bilateral
 Infection—usually unilateral
Can get discharge if abscess or infections (usually unilateral) (ex: puncture wounds)
 Mastitis
 Sebaceous cysts
 Certain medications
Nipple discharge—questions
 Color of discharge
 Onset
 Unilateral or bilateral
 Related to menses
 Assoc. symptoms
 On medication or oral contraceptives (antidepressants, diuretics, steroids)
Nipple discharge—descriptions
 Serous
 Thin and watery, may appear as yellow stain
 Intraductal papilloma (early stage)
 Carcinoma (under the nipple)
 Bilateral—oral contraceptives or other meds
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PHYS DX
Bloody
 Intraductal papilloma
 Malignant intraductal papillary carcinoma
 Can be very aggressive
Milky
 Milk
 Late pregnancy—lactation
 Persistent lactation—galactorrhea
 From massive hemorrhage in chil (?)  pituitary tumor (?)
 Certain tranquilizers
Risk factors—chart in library
 Benign
 Early menarche (< 12)
 Late menopause (>50)
 Nulliparity or low parity (0-2 kids)
 Late age at birth of 1st child (>30)
 High socioeconomic status
 Caffeine consumption (controversial)
 Fluid retention
 Breast cancer
 Age—80% occur after age 40
 Early menarche (<12)
 Late menopause (>50)
longer reproductive period
 Nulliparity
 Late age at birth of 1st child (>30)
 Personal history of premalignant masopathy
 Personal history of ovarian, endometrial, or colon cancer
 Family history of breast cancer
 Diet high in animal fats
 Obesity (more of a diagnostic factor) (harder to assess all tissue, may hide a mass)
 Harder to get a good mammogram on small-breasted women and men (less tissue), but too much
fat can obscure things also
 Vast majority in upper outer quadrant (includes the tail)
 Diagnostic ultrasound is a good way to check (Dr. Manello recommends this method)
Exam Procedures
 Inspection
 Pt seated, then supine
 Note symmetry
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PHYS DX
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Number, size, shape, symmetry, dimpling, redness, thickening, prominent vessels,
edema
 Supporting muscle affects symmetry
 Hands behind head—stretches skin to bring out asymmetries
 Hands on hips—pecs accentuated
 Bend over at waist—shows retraction
 Slight asymmetry in size is normal (usually dominant side larger)
 Breast tissue –usually ribs 2-6
 Well-endowed may go to rib 8
 From anterior to mid-axillary line (extension at sides)
Nipples
 Size, shape, symmetry, discharge, inversion, eversion
 Long standing inversion is usually normal
 Retracted
 Natural in some women but can become less so if stimulated
 Problem if didn’t use to be inverted
 Recent or fixed flattening or depression suggests retraction  suggests underlying
cancer
 Rashes or ulceration—Paget’s
 Discharge—serous, bloody, milky  CA
Dimpling
 Concavity in breast area
 From fibrosis, scar tissue, cancer (Table 10-1)
Deviation—bad sign
Edema of skin
 Associated with lymph blockage
 Can be cancer
 Orange peel sign (pits and puckering)
Abnormal contours
 Flattening, esp if asymmetric
Paget’s disease of nipple
 Starts as scaly, eczema-like lesion
 May weep, ooze, crust
 Progressive—does not go dormant
 Nipple and areola
 Erosive in nature
 Always assess scar tissue (esp if for BC)—a rash on old scar is often cancer or reoccurrence
 To bring out dimpling or retraction
1) raise arms over head  stretch skin
2) press hands against hips  contracts pecs
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9/30/98
PHYS DX
Palpation
 Supine
 Place pillow under pt’s shoulder on side of exam
 Proceed systematically—quadrant, linear, circular, zigzag
 Lotion or soapy water helps  skin drag
 Cover the entire breast
 Work in small, dime-sized circles
 Do not lift hand off breast until done
 Do 7-10 days after onset of menses
 Note consistency of tissue
 Normal varies widely
 Fibrocystic  nodularity
 May be painful during or after menses
 Note tenderness, mass, temp of skin
 Note lesions in clock method
 Size, distance from nipple
 Nodules
 Size
 Shape—round, regular (benign) or irregular (often malignant)
 Consistency—soft, firm, hard (often CA)
 Tenderness—usually benign, but may be late-stage intraductal papilloma
 Mobility—mobile (often benign) vs. fixed (often CA)
 May not feel a really deep nodule
 Palpate nipples
 Compress or strip
 Squeeze nipple and note any discharge
 Thickening or bloody discharge  CA
 Evaluate axillary nodes
 #, size, site, tenderness
 may get metastasis to spine, brain
 support woman’s arm
 Evaluate lateral, anterior and posterior axillary wall
 Check around clavicle sternum
 Mobility
 Rash—deodorant, dermatitis, shaving
 Infection—sweat glands infection
Video
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Review risk factors
Malignant—usually firm, irregular, fixed
Benign—usually soft, regular, mobile
Lymph nodes—usually small, soft, mobile
Teach patient how to do exam
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9/30/98
PHYS DX
 Mammograms
 Age 40-49  every 1-2 years
 After age 50  every year
 Can get brochures from American Cancer Society (ex: how to do exams)
 Diagnostic ultrasound (US)
 Can detect as small as 7 mm—self exams do 10mm
 Palpable
 10-12% of tumors are not found by mammogram
 10-12% of tumors are not found by US
 US can also spot cystic disease
 US best if have implants
 Baseline mammogram by age 40
 If family history do at age 30
 30-39  every 1-2 years
 over 40  every year
 can be a lot of radiographs (why Dr. M thinks US may be better
 if find a lump—get history of it