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BREAST AND AXILLAE

Non-child bearing lactation – galactorrhea

Extra nipples – supernumerary

Breast tissue in males – gynecomastia


Enlarged breast tissue

Breast development – thelarche

Surrounds the nipple – areola


Montgomery tubercles

Vdimpling of nipple – peau d’orange

Nipple discharge with pregnancy – colostrum

Symptom of breast malignancy – retraction

Clogged milk duct – mastitis

During a breast exam, the nurse will not check the mastectomy scar if a women has
a mastectomy within 2 years. FALSE

Annual mammograms are recommended for women 40 yrs and older. TRUE

Colostrum secretion may occur in the third trimester of pregnancy. TRUE

Paget disease is characterized by a red rash on the areola / nipple. TRUE

Breast tenderness and lumpiness is common the week prior to menstruation. TRUE

Most malignancies occur in the upper outer quadrant of the breast. TRUE

Lymph Node Sets: starting with axilla central axillary, suprascapular,


pectoral, brachial, superior and
inferior clavicular

Malignancy Findings:thickening of breast tissue, marked asymmetry, marked


discoloration (recent onset),
dimpling / puckering, retraction of areola or skin

Which of the following could be considered a risk factor for breast cancer for a
43-yr-old female?
Mother died of breast cancer
Menarche at age 11
50-yr-old sister currently has breast cancer
One child, a 7-yr-old son
A clear, milky white fluid expressed from the breast bud of a newborn infant is called
Witch’s milk

The axillary lymph nodes are Superficial

A nipple-related indication of a possible breast malignancy is called Retraction

While examining the breast of 52-yr-old woman, examiner notes nipple discharge.
What diagnostic tests would be appropriate?
Cytologic examination of discharge

Yvonne had a mastectomy of right breast 2 yrs. ago. What statement assists
examiner with breast examination of this patient?
If malignancy recurs, it may be at the scar site.

A supernumerary nipple is found on a white newborn infant girl. What may


accompany this finding?
Congenital renal or cardiac anomalies

While palpating the axilla, it is best to place the patient in a Sitting position with
the arms at the sides

58-yr-old woman asks the examiner how often a mammogram is recommended.


The best response by the examiner is Every 5 yrs

A clear-to-yellow viscous nipple discharge that is associated with pregnancy is called


Colostrum

What is the correct position in which to place the patient for breast palpation?
Supine with arms over the head and small pillow under the shoulder of the
side being assessed

During a breast examination, the examiner palpates a mass in a patient’s upper


outer breast. What can be done to further examine this mass?
Transilluminate the breast to detect presence of fluid in the mass

Female breast is composed of glandular tissue arranged into 15 to 20 lobes

A small nipple on the upper inner thigh is Supernumerary nipple

While performing a breast examination on a 68-yr-old female, which finding is


expected?
Breast tissue has a granular feel to it.
DEVELOPMENTAL VARIATIONS:
CHILDREN AND ADOLESCENTS
- childhood and preadolescence represent latent phase

thelarche – breast development


- early sign of puberty in adolescent girls

PREGNANT WOMEN
- lactiferous ducts proliferate and alveoli increase extensively in size and
number, which may cause breasts
to enlarge 2 to 3 prepregnancy size
- increase in glandular tissue displaces connective tissue so that tissue
becomes softer and looser
- areolae become more deeply pigmented and diameter increases
- nipples become more prominent, darker, and more erectile
- mammary vascularizaion increases, causing veins to engorge and become
visible as blue network beneath
skin surface

LACTATING WOMEN
- small amts of colostrum secrete from breasts
- colostrum contains more protein and minerals than does mature milk
and antibodies and other host
resistance factors
- replacing colostrum milk production begins 2 to 4 days after delivery in
response to surging prolactin levels,
declining estrogen levels, and stimulation of sucking
- breasts may become full and tense
- combined with tissue edema, a delay in effective ejection reflexes,
produces breast engorgement
- at termination of lactation, involution occurs over a periods of about 3 mos
- breast size decreases but rarely return to prelactation size

OLDER ADULTS
- after menopause, glandular tissue continues to atrophy gradually and is
replaced by fat deposited in
breasts
- breasts tend to hang more loosely
- nipples become smaller, flatter, and lose some erectile ability
- skin may take on relatively dry, thin texture
- loss of axillary hair may occur

I. REVIEW OF RELATED HISTORY


A. HISTORY OF PRESENT ILLNESS
1. Breast Discomfort - temporal sequence (onset, length, intermittent
symptoms), relationship to
menses, character, associated symptoms (lump, mass, discharge),
contributory factors (skin
irritation, strenuous activity, injury), medications
2. Breast Mass or Lump - temporal sequence (length of time first noted,
intermittent presence,
relationship to menses), symptoms (tenderness, pain, dimpling),
changes in lump,
associated symptoms, medications
3. Nipple Discharge - character (duration, color, consistency, odor, amt),
associated symptoms,
associated factors, medications

B. PAST MEDICAL HISTORY


- cancer, fibrocystic disease, surgeries, menstrual history, pregnancy,
lactation, past use of hormonal
medications

C. FAMILY HISTORY
- breast cancer (relatives, type, age of occurrence, treatment and
results), other breast disease in
female and male relatives

D. PERSONAL AND SOCIAL HISTORY- age, changes in breast characteristics, breast


changes during menstrual
cycle, date of 1st day of last menstrual period, menopause, breast
support, amt of caffeine intake,
self-examination, risk factors mammogram history, medications

II. EXAMINATION AND FINDINGS


A. BREAST SELF-EXAMINATION
- should be done once a month
- if menstruating, best time is 2 to 3 days after period ends

1. Steps:
- stand before mirror, inspect for anything unusual (discharge,
puckering, dimpling, scaling of
skin)
- clasp hands behind head and press hands forward
- press hands firmly on hips and bow slightly, pulling shoulders
and elbows forward
- raise left arm, use 3 or 4 fingers of right hand to explore left
breast firmly
- begin at outer edge, press flat part of fingers in small
circles, moving slowly around
breast
- gradually work toward nipple, covering entire breast
paying special attention to
area between breast and armpit
- gently squeeze nipple looking for discharge
- repeat exam on right breast

B. INSPECTION
1. Breast - patient in sitting position with arms hanging loosely
- inspect for size, symmetry, contour, skin color and texture,
venous patterns, and lesions
- perform this part of procedure on males and females
- inspect lower and lateral aspects for changes in color or texture
of skin
- often one breast is somewhat smaller than the other
- some men have breasts with convex shape
- skin texture should appear smooth and contour should be
uninterrupted
- retractions and dimpling signify contraction of fibrotic
tissue occurring with
carcinoma

peau d’orange – appearance of skin indicates edema of breast caused


by blocked lymph drainage
in advanced or inflammatory carcinoma

- venous patterns should be bilaterally similar


- unilateral venous patterns can be produced by dilated
superficial veins from
increased blood flow to malignancy
- changes in or recent appearance of any lesions always signals
need for closer
investigation

2. Nipple and Areola – should be round or oval and bilaterally equal or


nearly so
- color ranges from pink to black
- peppering of nontender, nonsuppurative Montgomery tubercles
is common
- surface should be smooth
- peau d’orange skin associated with carcinoma is often seen first
in areola
- most are everted, but one or bother may be inverted
- recent unilateral inversion or retraction of previously
everted nipple suggests
malignancy
- simultaneous bilateral inspection is necessary
- retraction is seen as flattening, withdrawal, or inversion of nipple
and indicates inward
pulling by inflammatory or malignant tissue
- fibrotic tissue of carcinoma can change axis of nipple,
causing it to point in a
direction different from the other nipple
- should be free of crusting, cracking, or discharge

supernumerary nipples, more common in black women, appear


as one or more extra
nipples located along embryonic mammary ridge (“milk
line”)
- may be pink or brown
- usually small, commonly mistaken for moles
- may be associated with congenital renal or cardiac
anomalies

3. Positions: seated with arms overhead


seated with hands pressed against hips (or pushing palms
together)
seated and leaning forward from waist
recumbent position

B. PALPATION
1. Breast - use finger pads because they are more sensitive than
fingertips
- essential to include tail of Spence, because most malignancies
occur in upper outer
quadrant of breast

tail of Spence – patient still in seated position, have her raise


arms over head, and palpate
tail (upper outer quadrant where armpit meets breast) as it
enters axilla, gently
compressing tissue between thumb and finger

- do complete light palpation and repeat examination with deeper,


heavier palpation
- try not to lift fingers off breast while moving form one point to
another
- in most men, expect to feel thin layer of fatty tissue overlying
muscle
- in females, breast tissue will feel dense, firm and elastic
- variation include lobular feel of glandular tissue and fine,
granular feel of breast
tissue in older women
- tenderness is common response to hormonal change
during menstrual cycle
- be aware of cycle because changes are most likely to
premenstrually and during
menses

2. Nipple – palpate on both male and female patients


- compress nipple between thumb and index finger and inspect for
discharge
- if discharge appears, note color and try to determine origin
by massaging radially
around areola while watching for discharge through
ductal opening on
nipple surface
- prepare smear for cytologic exam
3. Lymph Nodes – be sure to explore all sections of axilla (apex, central or
medial aspect along rib
cage, lateral aspect along upper surface of arm, anterior wall
along pectoral muscles, and
posterior wall along border of scapula)
- nodes are not usually palpable
- palpable nodes may be result of inflammatory or malignant
process
- should be described according to location, size, shape,
consistency, tenderness,
fixation, and delineation of borders
- any enlargement is highly significant
- Virchow nodes are 1st sign of invasion of lymphatics by
abdominal or thoracic
carcinoma

III. DEVELOPMENT VARIATIONS


A. INFANTS
- breast of many well infants, male and female, are enlarged for
relatively brief time
- result of passively transferred maternal estrogen
- if breast bud is gently squeezed, a small amt of clear or milky white
fluid, commonly called “witch’s
milk” is sometimes expressed
- enlargement is rarely more than 1 – 1.5 cm in diameter and can be
easily palpated
- usually disappears within 2 weeks, and rarely lasts beyond 3 mos
of age

B. ADOLESCENTS
- breast tissue of adolescent female feels homogenous, dense, firm, and
elastic
- malignancy is rare
- start self-exam early can establish healthy habit
- many males at puberty have transient or bilateral subareolar masses
- will most likely disappear within a year
- seldom enlarge to point of cosmetic surgery
- many experience gynecomastia, unusual and unexpected enlargement
that is readily noticeable
- temporary, benign, and resolves spontaneously
- if extreme, can be corrected surgically for psychologic or
cosmetic reasons
- can be associated with use of either illicit or prescription
drugs

C. PREGNANT WOMEN
- most changes become obvious during 1st trimester
- many experience sensation of fullness with tingling, tenderness, and
bilateral increase in size
- nipples enlarge and are more erectile
- later in pregnancy, nipples sometimes become flattened or
inverted
- areola broaden and darken
- Montgomery tubercles may appear
- palpation reveals generalized coarse nodularity (feel lobular because
of hypertrophy of mammary
alveoli)
- vascular spiders may develop on upper chest, arms, back, and face
- striae may be evident as a result of stretching

D. LACTATING WOMEN
- full breasts, which are firm, dense, and slightly enlarged, may become
engorged
- engorged breasts feel hard and warm and are enlarged, shiny,
and painful
- clogged milk ducts are relatively common
- may result from either inadequate emptying of breast or
brassiere that is too tight
- frequent nursing and/or expression of milk, along with local
application of heat, will help
open
- examine nipples for signs of irritation (redness and tenderness) and for
blisters or petechie
(precursors of overt cracking)
- after pregnancy, areolae and nipples tend to retain darker color, and
breasts become less firm than
prepregnant state
E. OLDER ADULTS
- postmenopausal breast may appear flattened, elongated, and
suspended more loosely from chest
wall
- finer, granular feel on palpation
- inframmary ridge thickens and can be felt more easily
- nipples become smaller and flatter

IV. COMMON ABNORMALITIES


FIBROCYSTIC DISEASE – benign cyst formation caused by ductal enlargement associated
with long follicular or luteal
phase of menstrual cycle
- cysts are tender and painful with increase of symptoms premenstrually
- occurs most commonly in women between 30 and 55 yrs. old

MALIGNANT BREAST TUMORS – peak incidence between ages 40 and 60 yrs, with 2/3
occurring in women under 65
- metastases occur through lymph and vascular systems
- mass or thickening in breast, marked symmetry of breasts, prominent
unilateral veins, discolorations, peau
d’orange, ulcerations, dimpling, puckering or retraction of skin or areola,
fixed inversion or deviation
in position of nipple, crusting or erosion of nipple or areola, change in
surface characteristics

ADULT GYNECOMASTIA – smooth, firm, mobile, tender disk of breast tissue located
behind areola in males
- may be unilateral or bilateral
- can be caused by hormone imbalance, by testicular, pituitary, or hormone-
secreting tumors, liver failure, or
by antihypertensive medications or those containing estrogens or
steroids

GALACTORRHEA – lactation not associated with child-bearing most commonly caused by


drugs
- causes include prolactin-secreting tumors, pituitary tumors, hypothyroidism,
Cushing syndrome, and
hypoglycemia

GYNECOMASTIA – enlargement of breast tissue caused by puberty, hormonal


imbalance, testicular or pituitary tumors,
and medications containing estrogens or steroids

PREMATURE THELARCHE – prepubertal breast enlargement of unknown cause in girls can


occur in absence of other
signs of sexual maturation
- degree of enlargement varies from very slight to fully developed
- usually occurs bilaterally

MASTITIS – inflammation and infection of breast tissue characterized by sudden onset


of swelling, tenderness,
erythema, and heat, accompanied by chills, fever, and increased pulse rate
- most common in lactating women after milk is established, usually 2nd or 3rd
wk after delivery
- not an indication to discontinue breast-feeding
- abscess formation can result presenting discharge of pus and large,
hardened mass
- underlying pus-filled abscess may appear as bluish tint to skin