Chapter 16 Breasts and Axillae

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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 3

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. 4

Females Inspect with patient seated. Compare breasts Inspect both areolae and nipples 5

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 6

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. 7

Males 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. 8

Breasts Glandular tissue Fibrous tissue Lactiferous ducts drain milk from each lobe onto nipple surface. Fibrous tissue 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 9

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 10

Breasts (Cont.) Lymphatic network Nipple Deep lymphatics drain mammary lobules Complex of axillary lymph nodes Nipple Sebaceous glands (Montgomery tubercles) on areola 11

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 12

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Pregnant Women Areolae: Vascularization increases. increases in size and number due to placental hormones pigment increases become more erect Vascularization increases. Milk is produced 2-4 days after delivery 14

History of Present Illness Breast mass or lump Breast discomfort Nipple discharge 15

History of Present Illness (Cont.) Breast enlargement in men History of hyperthyroidism, testicular tumor, Klinefelter syndrome Medications Treatment for prostate cancer: androgens or GnRH analogues Illicit and/or recreational drugs: anabolic steroids, marijuana 16

History (Cont.) Changes in breast characteristics Risk factors for breast cancer Mammogram and other breast imaging history Family history First day of last menstrual period Pregnancy and lactation Menopause Breast self-examination (BSE) 17

Inspection/ Palpation Peau-d’orange is edema on or around the nipple and is from blocked lymph nodes Nipple and areola—The 5 D’s Discharge Depression or inversion Discoloration Dermatologic changes Deviation 18

Inspection/Palpation Inspect breasts in varied positions. Seated with arms extended over head or flexed behind neck Hands pressed on hips with shoulder rolled forward Seated and leaning forward from waist Supine with arms above head with towel under shoulder 19

Palpation Document masses found. Nipples Discharge Tail of Spence Both axillae 20

Palpation (Cont.) Males Expect to feel a thin layer of fatty tissue overlying muscle. Gynecomastia Have patient hang arms at sides 21

Infants Breasts of many well newborns, male and female, are enlarged for a relatively brief time. Result of passively transferred maternal estrogen 22

Adolescents Breast tissue is based on Tanner stages Gynecomastia Unusual and unexpected 23

Pregnant Women Inspection Palpation Increase in size Tenderness and tingling Enlarged erect nipples Vascular spiders and striae Palpation Colostrum Coarse nodularity of breast tissue Dilated subcutaneous veins Engorgement 24

Abnormalities (Breasts) Paget disease Surface manifestation of underlying ductal cancer Mastitis Inflammation and infection of the breast tissue Fibrocystic changes Benign fluid-filled cyst formation caused by ductal enlargement Galactorrhea Lactation not associated with childbearing 25

Abnormalities (Breast Lumps) Malignant breast tumors Ductal cancer arises from the epithelial lining of ducts Lobular cancer originates in the glandular tissue of the lobules Fibroadenoma Benign tumors composed of stromal and epithelial elements that represent a hyperplastic or proliferative process in a single terminal ductal unit 26

Abnormalities (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 27

Breast Self Exam http://www.breasthealthinfo.com