Breasts And Axillae

Front 1

Breast

Back 1

 Paired nippled mammary glands on anterior chest wall

Front 2

breast position in females

Back 2

 From 2/3 rib to 6/7 rib
 Sternal margin to midline

Front 3

male component of breasts

Back 3

 Nipple/areola
 Thin layer of breast tissue

Front 4

female component of breasts

Back 4

 Nipple/areola
 Glandular tissue
 Fibrous tissue
 Subcutaneous fat
 Retromammary fat

Front 5

glandular tissue

Back 5

 15-20 lobes per breast
 each lobe is composed of 20 to 40 lobules; each lobules consists of milk producing acini cells that empty into lactiferous ducts.
 Radiate about nipple
 Milk-producing cells
 each lobules consists of milk producing acini cells that empty into lactiferous ducts.
 Lactiferous ducts
 each lobules consists of milk producing acini cells that empty into lactiferous ducts.
 A lactiferous duct drains milk from each lobe into the surface of the nipple
 Fibrous tissue
 Subcutaneous
 the layer of subcutaneous fibrous tissue provide support for the breast
 Provides breast support
 the layer of subcutaneous fibrous tissue provide support for the breast
 Suspensory ligaments
 suspensory ligaments (Cooper ligaments) extend from the connective tissue layer through the breast and attach to the underlying muscle fascia

Front 6

breast muscle

Back 6

 forms the floor of the breast
 Pectoralis major/minor
 Serratus anterior
 Latissimus dorsi
 Subscapularis
 External oblique
 Rectus abdominus

Front 7

breast vascular supply

Back 7

 provides most of the blood supply to the deeper tissues of the breast and the nipple
 Internal mammary artery
 Lateral thoracic artery

Front 8

Subcutaneous/retromammary fat

Back 8

 Supplies bulk of breast
 the subcutaneous and retromammary fat that surrounds the glandular tissue constitutes most of the bulk of the pressed against the breast itself consistency
 Varies with age/pregnancy/lactation/genetics
 the proportions of each of the component tissues vary with age, nutritional status, pregnancy, lactation, and genetic predisposition

Front 9

 Five segments (exam purposes)

Back 9

 Upper outer quadrant
 the greatest amount of glandular tissue lies in the upper outer quadrant
 Upper inner quadrant
 Lower inner quadrant
 Lower outer quadrant
 Tail of Spence
 Breast tissue extends from the upper outer quadrant into the axilla, forming a tail of Spence.
 In the axilla the mammary tissue is in direct contact with the axillary lymph nodes

Front 10

 the greatest amount of glandular tissue lies in which breast quadrant

Back 10

upper outer quadrant

Front 11

 Nipple

Back 11

 Lactiferous ducts empty here
 Montgomery Tubercles
 tiny sebaceous glands that may be apparent on the areola surface
 Supernumerary Nipple
 sometimes present along the mammary ridge that extends from the axilla to the groin

Front 12

 Montgomery Tubercles

Back 12

 tiny sebaceous glands that may be apparent on the areola surface

Front 13

 Supernumerary Nipple

Back 13

 sometimes present along the mammary ridge that extends from the axilla to the groin

Front 14

 Lymph Nodes:Breast

Back 14

 Drains breast
 Superficial lymphatics drain skin
 Deep lymphatics drain mammary lobules

Front 15

Lymph Nodes: Axillary

Back 15

 more superficial and accessible to palpation when enlarged
 Anterior
 the anterior axillary (pectoral) nodes are located along the lower border of the pectoralis major inside the lateral axillary fold
 Central
 the midaxillary (central) nodes are high in the axilla close to the ribs
 Posterior
 the posterior axillary (sub scapular) nodes lie along the lateral border of the scapula and deep in the posterior axillary fold
 Lateral
 axillary (brachial) nodes can be felt along the upper humorous

Front 16

 Anatomy and Physiology: Children/Adolescents: BREAST DEVELOPMENT

Back 16

 Thelarche early sign of puberty
 Thelarche is the earliest sign of breast development, breast bud.
 Tanner’s five stages of sexual maturity
 in using the Tanner charts to stage breast development, it is important to note temporal relationships.
 It is unusual for the onset of menses to occur before stage III.
 About 25% females beginning menstruation at stage III
 approximately 75% are menstruating at stage IV and are beginning a regular menstrual cycle.
 About 10% of young women do not begin to menstruate until stage V
 the average interval from the appearance of the breast bud (stage II) to menarche is two years
 Breasts develop individually/may cause asymmetry

Front 17

what is the earliest sign of puberty in females

Back 17

 Thelarche is the earliest sign of breast development, breast bud.

Front 18

 Anatomy and Physiology:
Pregnant Women

Back 18

 Lactiferous ducts proliferate
 in response to luteal and placental hormones
 Alveoli increase in size/number
 in response to luteal and placental hormones
 Breasts enlarge 2- to 3-fold
 because of the increasing R size and number
 Colostrum produced
 toward the end of pregnancy, as epithelial secret Tory activity increases, colostrum is produced in accumulates in the acinis cells (alveoli).
 Areolar pigment increases
 Areolae more erect
 Vascularization increases
 mammary vascularization increases, causing pains to engorge become visible as a blue network beneath the surface of the skin.

Front 19

 Anatomy and Physiology:
Lactating Women

Back 19

 Colostrum secreted by nipples
 the first few days after delivery, small amounts of colostrum secreted from the breasts.
 Colostrum contains more protein and minerals than does the terminal
 colostrum also contains antibodies and other host resistance factors
 Milk produced 2-4 days post delivery
 milk production to replace colostrum begins 2 to 4 days after delivery in response to surging prolactin levels, declining estrogen levels, and the stimulation of sucking
 Breasts full and tense
 as the alveoli and lactiferous ducts fill, the breasts may become full and tense
 this, combined with tissue edema and the delay in effective ejection reflexes, produces breast engorgement.
 Involution period
 after termination of lactation, involution occurs over a period of about three months.
 Breasts size decreases without loss of lobular and R components; the press rarely return to their pre-lactation size

Front 20

 Anatomy and Physiology:
Older Adults

Back 20

 Decrease in glandular tissue
 after menopause, glandular tissue atrophies gradually and is replaced by fat
 Inframammary ridge thickens
 Breasts hang loosely
 as a result of tissue changes and relaxation of the suspensory ligaments
 Nipples smaller/flatter
 Hair decrease in axilla

Front 21

Present Problem:  Breast discomfort

Back 21

 Temporal sequence
 temporal sequence: onset gradual or sudden; length of time symptom has been present; just symptom come and go or is it always present
 Relationship to menses
 timing, severity
 Character
 stinging, pulling, burning, drying, stabbing, aching, throbbing; unilateral or bilateral; localization; radiation
 Associated symptoms
 lump or mass, discharge from nipple
 Contributory factors
 skin irritation under breast from tissue tissue contact or from rubbing of undergarments; strenuous activity; recent injury to breast
 Medications
 hormones are bio identical hormones

Front 22

Present Problem: Breast lump/mass

Back 22

 Temporal sequence
 length of time since lump first noted; does lump come and go or is it always present; relationship to menses
 Symptoms
 tenderness or pain (stinging, pulling, burning, drying, stabbing, aching, throbbing; unilateral or bilateral; localization; radiation), dimpling or changing contour
 Changes in lump
 size, character, relationship to menses (timing or severity)
 Associated symptoms
 nipple discharge or retraction, tender lymph nodes
 Medications
 hormones are bio identical hormones

Front 23

Present Problem: Nipple discharge

Back 23

 Character
 spontaneous or provoked; unilateral or bilateral, onset gradual or sudden, duration, color, consistency, odor, amount
 Associated symptoms
 nipple retraction; breast lump or discomfort
 Associated factors
 relationship to menses or other activities; recent injury to breast
 Medications
 contraceptives; hormones, phenothiazines, digitalis, diuretics, steroids

Front 24

Present Problem: breast enlargement in men

Back 24

 history of hypothyroidism, testicular tumor, Klinefelter syndrome
 medications: cimetidine, omeprazole, spironolactone, finasteride, some antihypertensives, some antipsychotics
 treatment for prostate cancer but anti-androgens or gonadotropin releasing hormone analogues
 illicit/or recreational drugs: anabolic steroids, marijuana

Front 25

 Related History: Past Medical History

Back 25

 Previous breast disease
 cancer, fibroadenoma, fibrocystic changes
 Surgeries
 breast biopsies, aspirations, implants, reductions, reconstructions, for activity
 Menstrual history
 first day of last menstrual period; age at menarche and menopause; cycle length, duration and amount of flow, regularity; associated breast symptoms (nipple discharge; pain or discomfort)
 Pregnancies
 age at each pregnancy, length of each pregnancy, date of delivery or termination
 Lactation
 lactation: number of children breast-fed; duration of time for breast-feeding; date of termination of last breast-feeding; medication used to suppress lactation
 Hormonal medications
 name and dosage, reason for use (contraception, menstrual control, menopausal symptom relief), length of time of hormones, date of termination

Front 26

 Related History: Family History

Back 26

 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 (breast ovarian cancers syndrome, HNCPP, Li-Fraumeni syndrome, or Cowden syndrome)
 Other breast disease
 type of disease; age at time of occurrence; treatment and results

Front 27

 Related History:
Personal/Social History

Back 27

 Changes in breast characteristics
 Breast changes with menstrual cycle
 LMP/menopause
 Breast support
 BSE/mammography
 Breast disease risk factors
 The primary risk factors for breast cancer are female sex, age, lack of childbearing or breastfeeding, higher hormone levels, race, economic status and dietary iodine deficiency.
 Most cases of breast cancer cannot be prevented through any action on the part of the affected person. The World Cancer Research Fund estimated that 38% of breast cancer cases in the US are preventable through reducing alcohol intake, increasing physical activity levels and maintaining a healthy weight. It also estimated that 42% of breast cancer cases in the UK could be prevented in this way, as well as 28% in Brazil and 20% in China.
 Smoking tobacco may increase the risk of breast cancer with the greater the amount of smoking and the earlier in life smoking begins the higher the risk.
 In a study of attributable risk and epidemiological factors published in 1995, later age at first birth and not having children accounted for 29.5% of U.S. breast cancer cases, family history of breast cancer accounted for 9.1% and factors correlated with higher income contributed 18.9% of cases.
 Attempts to explain the increased incidence (but lower mortality) correlated with higher income include epidemiologic observations such as lower birth rates correlated with higher income and better education, possible overdiagnosis and overtreatment because of better access to breast cancer screening, and the postulation of as yet unexplained lifestyle and dietary factors correlated with higher income. One such factor may be past hormone replacement therapy, which was typically more widespread in higher income groups.
 The genes associated with hereditary breast-ovarian cancer syndromes usually increase the risk slightly or moderately; the exception is women and men who are carriers of BRCA mutations. These people have a very high lifetime risk for breast and ovarian cancer, depending on the portion of the proteins where the mutation occurs. Instead of a 12 percent lifetime risk of breast cancer, women with one of these genes have a risk of approximately 60 percent.
 In more recent years, research has indicated the impact of diet and other behaviors on breast cancer. These additional risk factors include a high-fat diet, alcohol intake, obesity, and environmental factors such as tobacco use, radiation, endocrine disruptors and shiftwork. Although the radiation from mammography is a low dose, the cumulative effect can cause cancer.
 In addition to the risk factors specified above, demographic and medical risk factors include:
 Personal history of breast cancer: A woman who had breast cancer in one breast has an increased risk of getting a second breast cancer.
 Family history: A woman's risk of breast cancer is higher if her mother, sister, or daughter had breast cancer, the risk becomes significant if at least two close relatives had breast or ovarian cancer. The risk is higher if her family member got breast cancer before age 40. An Australian study found that having other relatives with breast cancer (in either her mother's or father's family) may also increase a woman's risk of breast cancer and other forms of cancer, including brain and lung cancers.
 Certain breast changes: Atypical hyperplasia and lobular carcinoma in situ found in benign breast conditions such as fibrocystic breast changes are correlated with an increased breast cancer risk.
 Those with a normal body mass index at age 20 who gained weight as they aged had nearly double the risk of developing breast cancer after menopause in comparison to women who maintained their weight. The average 60-year-old woman's risk of developing breast cancer by age 65 is about 2 percent; her lifetime risk is 13 percent.[37]
 Medications
 Alcohol use

Front 28

 Breast disease risk factors

Back 28

 The primary risk factors for breast cancer are female sex, age, lack of childbearing or breastfeeding, higher hormone levels, race, economic status and dietary iodine deficiency.
 Most cases of breast cancer cannot be prevented through any action on the part of the affected person. The World Cancer Research Fund estimated that 38% of breast cancer cases in the US are preventable through reducing alcohol intake, increasing physical activity levels and maintaining a healthy weight. It also estimated that 42% of breast cancer cases in the UK could be prevented in this way, as well as 28% in Brazil and 20% in China.
 Smoking tobacco may increase the risk of breast cancer with the greater the amount of smoking and the earlier in life smoking begins the higher the risk.
 In a study of attributable risk and epidemiological factors published in 1995, later age at first birth and not having children accounted for 29.5% of U.S. breast cancer cases, family history of breast cancer accounted for 9.1% and factors correlated with higher income contributed 18.9% of cases.
 Attempts to explain the increased incidence (but lower mortality) correlated with higher income include epidemiologic observations such as lower birth rates correlated with higher income and better education, possible overdiagnosis and overtreatment because of better access to breast cancer screening, and the postulation of as yet unexplained lifestyle and dietary factors correlated with higher income. One such factor may be past hormone replacement therapy, which was typically more widespread in higher income groups.
 The genes associated with hereditary breast-ovarian cancer syndromes usually increase the risk slightly or moderately; the exception is women and men who are carriers of BRCA mutations. These people have a very high lifetime risk for breast and ovarian cancer, depending on the portion of the proteins where the mutation occurs. Instead of a 12 percent lifetime risk of breast cancer, women with one of these genes have a risk of approximately 60 percent.
 In more recent years, research has indicated the impact of diet and other behaviors on breast cancer. These additional risk factors include a high-fat diet, alcohol intake, obesity, and environmental factors such as tobacco use, radiation, endocrine disruptors and shiftwork. Although the radiation from mammography is a low dose, the cumulative effect can cause cancer.
 In addition to the risk factors specified above, demographic and medical risk factors include:
 Personal history of breast cancer: A woman who had breast cancer in one breast has an increased risk of getting a second breast cancer.
 Family history: A woman's risk of breast cancer is higher if her mother, sister, or daughter had breast cancer, the risk becomes significant if at least two close relatives had breast or ovarian cancer. The risk is higher if her family member got breast cancer before age 40. An Australian study found that having other relatives with breast cancer (in either her mother's or father's family) may also increase a woman's risk of breast cancer and other forms of cancer, including brain and lung cancers.
 Certain breast changes: Atypical hyperplasia and lobular carcinoma in situ found in benign breast conditions such as fibrocystic breast changes are correlated with an increased breast cancer risk.
 Those with a normal body mass index at age 20 who gained weight as they aged had nearly double the risk of developing breast cancer after menopause in comparison to women who maintained their weight. The average 60-year-old woman's risk of developing breast cancer by age 65 is about 2 percent; her lifetime risk is 13 percent.[37]

Front 29

 Related History: Pregnant Women

Back 29

 Sensations
 fullness, tingling, tenderness
 Use of support bra
 Knowledge of breast feeding
 Plans to breast feed

Front 30

 Related History: Lactating Women

Back 30

 Breast cleaning
 use of soap products that can remove natural lubricants, frequency of use; nipple preparations
 Nursing bra
 Nipples
 tenderness, pain, cracking, bleeding; retracted; related problems feeding; exposure to air
 Associated problems
 engorgement, leaking breast, plugged duct (localized tenderness and mom), fever, infection; treatment and results; increase with oral candidal infection.
 Nursing routine
 length of feeding, frequency, rotation of breast, position's used
 Breast milk
 Cultural beliefs
 Medications that cross milk/blood barrier

Front 31

 Related History: Older Adults

Back 31

 Skin irritation under breasts
 skin irritation under pendulous breast tissue to tissue contact or for rubbing of undergarments; treatment
 Hormone therapy
 hormone therapy during or since menopause: name and dosage of medication: duration of therapy

Front 32

 Exam & Findings: Breast Self-Exam

Back 32

 Have patient demonstrate BSE
 Instruct on correct techniques
 stand before mirror. Inspect both breasts for anything unusual, such as skin redness, discharge from the nipples, puckering, dimpling, or scaling of the skin
 the next two steps are designed to emphasize any change in the shape or contour of your breasts. As you do them, you should be able to feel your chest muscles tighten
 watch closely in the mirror, clasp hands behind your head and swing elbows forward
 next, press hands firmly on hips and bow slightly toward the mirror as you pull your shoulders and elbows forward
 some women do next part of the examination in the shower. Fingers glide over soapy skin, making it easy to appreciate the texture underneath
 raise your left arm. Use three or four fingers of your right hand to explore your left breast firmly, carefully, and thoroughly. Beginning at the outer edge, press the flat part of your fingers in small circles moving the circle slowly around the breast. Gradually work toward the nipple. Be sure to cover the entire breast. Pay special attention to the areas between the breast and the armpit, including the armpit itself. Feel for any unusual lumber mass under the skin
 step four should be repeated lying down. Lie flat on your back, left arm over your head and pillow or folded towel under your left shoulder. This position flattens depressed and makes it easier to examine. Use the same circular motion described earlier.
 Repeat on your right breast.

Front 33

Self breast exam technique

Back 33

 stand before mirror. Inspect both breasts for anything unusual, such as skin redness, discharge from the nipples, puckering, dimpling, or scaling of the skin
 the next two steps are designed to emphasize any change in the shape or contour of your breasts. As you do them, you should be able to feel your chest muscles tighten
 watch closely in the mirror, clasp hands behind your head and swing elbows forward
 next, press hands firmly on hips and bow slightly toward the mirror as you pull your shoulders and elbows forward
 some women do next part of the examination in the shower. Fingers glide over soapy skin, making it easy to appreciate the texture underneath
 raise your left arm. Use three or four fingers of your right hand to explore your left breast firmly, carefully, and thoroughly. Beginning at the outer edge, press the flat part of your fingers in small circles moving the circle slowly around the breast. Gradually work toward the nipple. Be sure to cover the entire breast. Pay special attention to the areas between the breast and the armpit, including the armpit itself. Feel for any unusual lumber mass under the skin
 step four should be repeated lying down. Lie flat on your back, left arm over your head and pillow or folded towel under your left shoulder. This position flattens depressed and makes it easier to examine. Use the same circular motion described earlier.
 Repeat on your right breast.

Front 34

 Review breast cancer screening

Back 34

 BSE - Breast Self Exam
 CBE – Clinical Breast Exam
 younger than 40 years of age: everyone to three years
 older than 40 years of age: annually
 Mammogram
 Over 50
 Over 40 if high risk

Front 35

When do get a mammogram

Back 35

Over 50 years old

over 40 years old if high risk

Front 36

When to get a clinical breast examination

Back 36

 younger than 40 years of age: every 1-3 years
 older than 40 years of age: annually

Front 37

how often to do a self breast exam

Back 37

 Optional
 Monthly starting at age 20s
 Women should be familiar with their breasts and report any changes to their health care provider.

Front 38

 Exam & Findings: Inspection: positions

Back 38

 Seated with arms hanging loosely
 Seated arms over head
 Seated with hands on hips
 Seated and leaning forward
 supine

Front 39

breast inspection

Back 39

 Size
 Symmetry
 often one breast is somewhat smaller than the other
 Contour
 alterations and contour are best seen on bilateral comparison of one breast with the other.
 Retractions in dimpling signify the contraction of fibrotic tissue that may occur with carcinoma.
 size
 women's breasts vary in shape, from convex to pendulous or conical, and often one breast is somewhat smaller than the other
 men's breasts are generally even with the chest wall, although some men, particularly those who are overweight, have breasts with a convex shape
 Skin color and texture
 the skin texture should appear smooth and the contour should be uninterrupted
 a peau d’orange appearance of the skin indicates edema the press caused by blocked lymph drainage and advanced laboratory occurs,
 the skin appears thickened with large pores and accentuated skin markings
 healthy skin may look similar if the pores of the skin large
 Venous patterns
 venous patterns maybe visible, although they are usually pronounced only in the breasts of pregnant or obese women
 venous patterns should be bilaterally similar.
 Unilateral venous patterns can be produced by dilated superficial veins as a result of increased blood flow to a malignancy.
 This requires further investigation
 Lesions

Front 40

 Nipple/areola inspection

Back 40

 Discharge
 should be free of discharge
 Depression/inversion
 most nipples are everted, but one or both nipples may be inverted, with the nipple tucked inward.
 In these instances, asked whether this lifetime history of inversion
 recent unilateral inversion of a previously everted nipple suggest malignancy
 Discoloration
 should be a homogenous color and match that of the areola
 Dermatologic changes
 may be either smooth or wrinkled but should be free of cresting, cracking, or discharge
 areola color varies from light pink a very dark brown or black
 Deviation
 simultaneous bilateral inspection is necessary to detect nipple retraction or deviation.
 Retraction is seen as a flattening or pulling back of the nipple and areola, which indicates inward pulling by inflammatory or malignant tissue.
 The fibrotic tissue of carcinoma can also change the axis of the nipple, causing it to point in a different direction from that of the other nipple

Front 41

 Supernumerary nipples

Back 41

 more common in black women than white women
 appear as one or more extra nipples located along the embryonic mammary ridge (the "milk line")
 these nipples and areolae may be pink or brown, are usually small, and are commonly mistaken for moles
 infrequently, some glandular tissue may accompany these nipples
 in some cases, supernumerary nipples may be associated with congenital renal or cardiac anomalies, particularly in whites

Front 42

 Exam & Findings: Palpation: position

Back 42

 Seated
 seated with arms overhead or flexed behind neck
 this adds tension to the suspensory ligaments, accentuating dimpling in may reveal variations and contour in symmetry
 seated with hands pressed against hips was shoulders rolled forward (or alternatively have the patient push her palms together)
 this contract the pectoral muscles, which can reveal deviations and contour in symmetry
 seated in leaning forward from the waist
 this also causes tension in the suspensory ligaments
 the breasts should hang equally
 this maneuver can be particularly helpful in assessing the contour in symmetry of large breast, because of breast fall away from the chest wall and hang freely
 as the patient leans forward, support her by the hands
 Supine
 have the patient raise one arm behind her head
 place a small pillow or folded towel under that shoulder to spread the breasts tissue more evenly over the chest wall
 the ideal position for examination is that the nipple pointing toward the ceiling
 women with large breast may need to roll slightly to achieve this position

Front 43

Exam & Findings: palpation technique

Back 43

 palpate each breasts separately
 palpate all areas of the breast, feeling for lumps or nodules (remember that breast tissue extends from the second or third rib to the sixth or seventh rib, and from the sternal margin to the midaxillary line.)
 It is essential to include the tail of Spence and palpation
 recall that the greatest amount of glandular tissue lies in the upper outer quadrant of the breast tissue extending from this quadrant into the axilla to form the tail of Spence.
 Palpate using your finger pads because they are more sensitive than the fingertips
 palpate systematically, pushing gently but firmly tour the abdominal wall as you are to your fingers in a clockwise or counterclockwise pattern
 at each point, as you rotate your fingers, press inward using three depths of palpation: light, then medium, and finally deep
 the exact sequence you select for palpation is not critical, but a systematic approach will help ensure that all portions of the breast are examined
 regardless of the method, glide your fingers from one point to the next. Avoid lifting your fingers off the breast tissue because doing so makes it easy to miss tissue
 at the completion of the examination, return to the nipple and with two fingers gently depressed the tissue inward into the wall behind the areola. Your fingers and tissue should move easily inward
 nipple compression should be performed only if the patient reports spontaneous nipple discharge
 determine whether the discharge is he bilateral or unilateral
 use a magnifying glass to look closely at the nipple to determine whether the discharges from a single duct multiple ducts.
 Characteristics of concern include spontaneous discharge that is unilateral and from a single duct
 collect a sample on a glass slide for cytologic evaluation

Front 44

Breasts: Female

Back 44

 breast tissue will fill dense, firm, and elastic
 expected variations include the lobular feel of glandular tissue (soft non-discreet bombs diffusely dispersed throughout the breast tissue) and the fine, granular feel of breast tissue in older women
 a firm transverse ridge of compressed tissue (infra mammary ridge) may be felt along the lower edge of the breast. It is easy to mistake this for a breast mass
 a cyclical pattern of breast enlargement, increased modularity, and tenderness is a common response to hormonal changes during the menstrual cycle
 be aware of where the woman is in her cycle because these changes are most likely to occur premenstrual he entering menses.
 They are least noticeable during the week after menstrual flow

Front 45

Breasts: Male

Back 45

 in most men, expect to feel a thin layer of fatty tissue overlying muscle.
 Obese men may have somewhat thicker fatty skin, giving the appearance of enlarged breasts.
 A firm disk of glandular tissue may be felt in some men

Front 46

 Exam & Findings: Palpation

Back 46

 Tail of Spence
 Both axillae
 Masses
 Nipples
 Males and females
 Compress to check for discharge
 Discharge
 Note color/origin
 Prepare smear for cytology
 Lymph nodes
 Males and females
 Both axillae/supraclavicular areas
 Nodes should not be palpable

Front 47

Masses documentation

Back 47

 Document masses found
 Location
 Size
 Shape
 Consistency
 Tenderness
 Mobility
 Borders
 Retraction

Front 48

 Exam & Findings: Infants: INSPECT

Back 48

 Enlarged breasts
 the breasts of many well newborn, male and female, or enlarged for relatively brief time
 the enlargement may be noted at birth and is a result of passively transferred maternal estrogen
 the enlargement is rarely more than 1 to 1.5 cm in diameter and can be easily palpated behind the nipple.
 It usually disappears within two weeks and rarely last beyond three months of age

Front 49

Exam & Findings: Infants:PALPATE

Back 49

Witch’s milk”
 if you squeeze the breast bud gently, a small amount of clear milky white fluid, commonly called "witches milk," is sometimes expressed

Front 50

 Exam & Findings: Adolescents: INSPECTION

Back 50

 Asymmetrical breasts
 the right and left breasts of the adolescent female may not develop at the same rate
 reassure the girl that this asymmetry is common in letterpress are developing appropriately
 Transient subareolar masses
 many males puberty have transient or unilateral or bilateral subareolar masses.
 These are firm, sometimes tender, and are often a source of great concern to the patient and his parents
 reassure them that these breast buds will most likely disappear within a year
 they seldom enlarge to a point of cosmetic difficulty
 Gynecomastia
 an unusual and unexpected enlargement in pubescent males that is readily noticeable
 fortunately, it is usually temporary and benign and resolve spontaneously
 if the enlargement is extreme, it can be corrected surgically for psychological or cosmetic reasons
 in rare instances, biopsy is required to rule out the presence of cancer
 gynecomastia can be associated with the use of other illicit prescription drugs
 symptoms resolve after the drugs are discontinued
 Cysts

Front 51

Exam & Findings: Adolescents: PALPATION

Back 51

 Breast tissue should be dense, firm, and elastic

Front 52

 Exam & Findings: Pregnant Women: INSPECTION

Back 52

 Inspection
 Increase in size
 Tenderness and tingling
 associated with fullness of breasts
 Enlarged erect nipples
 as the pregnancy progresses, the nipples will sometimes become flattened or inverted
 a crossed caused by dry colostrum can be evident on the nipple
 Vascular spiders
 during the second trimester, vascular spiders may develop on the upper chest, arms, neck, and face as a result of elevated levels of circulating estrogen
 the spiders are bluish in color and do not blanch with pressure
 Striae
 may be evident as a result of stretching as the breasts increase in size

Front 53

Exam & Findings: Pregnant Women: PALPATION

Back 53

 Colostrum
 Coarse nodularity of breast tissue
 because of hypertrophy of the mammary alveoli
 Dilated subcutaneous veins
 make creating network of blue tracing across the rest

Front 54

 Exam & Findings: Lactating Women: PALPATION

Back 54

 Palpate breasts
 Engorgement
 engorged breasts feel hard and warm in our enlarged, shiny, and painful.
 Engorgement is not an unusual condition in the first 24 to 48 hours after the breasts fill with milk; however, it's later development may signal the onset of mastitis
 Clogged milk ducts
 clogged milk ducts are relatively common occurrence in lactating women
 a clogged duct may result from either inadequate emptying of the breasts or a brassiere that is too tight
 a clogged duct will create a tender spot on the breasts that may feel lumpy and hot
 frequent nursing and/or expression of milk, along with local application of heat, will help open the duct.
 A clogged duct left unattended may result in the development of mastitis

Front 55

Exam & Findings: Lactating Women: INSPECTION

Back 55

 Irritation
 redness or tenderness
 Blisters
 Petechiae
 precursors of overt cracking
 Cracking
 cracked nipples will be sore and maybe bleeding

Front 56

 Exam & Findings: Older Adults: INSPECTION

Back 56

 Elongation/flattening
 the breast and postmenopausal women may appear flattened, elongated, and suspended more loosely from the chest wall as a result of glandular tissue atrophy relaxation of the sensory ligaments
 Hanging tissue
 the breast and postmenopausal women may appear flattened, elongated, and suspended more loosely from the chest wall as a result of glandular tissue atrophy relaxation of the sensory ligaments
 Smaller nipple size

Front 57

Exam & Findings: Older Adults: PALPATION

Back 57

 Fine granular glandular tissue
 a finer, granular feel on palpation replaces the lobular feel of glandular tissue
 Thickened inframammary ridge
 can be felt more easily
 Fluid-filled cysts
 hormone replacement therapy can result in fluid flow process, which can be painful

Front 58

Breast Masses: fibrotic changes

Back 58

 age range
 20 to 49
 Occurrence
 usually bilateral
 number
 multiple or single
 shape
 round
 consistency
 soft the firm; tense
 mobility
 mobile
 retraction signs
 absent
 tenderness
 usually tender
 borders
 well delineated
 variation with menses
 yes

Front 59

Breast Masses: fibroadenoma

Back 59

 age range
 15 to 55
 Occurrence
 usually bilateral
 number
 single; may be multiple
 shape
 round or discoid
 consistency
 firm or rubbery
 mobility
 mobile
 retraction signs
 absent
 tenderness
 usually nontender
 borders
 well delineated
 variation with menses
 no

Front 60

Breast Masses: cancer

Back 60

 age range
 30 to 80
 Occurrence
 usually unilateral
 number
 single
 shape
 irregular or stellate
 consistency
 hard, stone like
 mobility
 fixed
 retraction signs
 often present
 tenderness
 usually nontender
 borders
 poorly delineated; irregular
 variation with menses
 no

Front 61

 Common Abnormalities: fibrocystic disease

Back 61

 Definition
 benign fluid filled cyst formation caused by ductal enlargement
 pathophysiology
 usually bilateral and multiple
 common in women 30 to 55 years of age
 associated with long follicular oral luteal phase of the menstrual cycle
 subjective data
 tender and painful breasts and/or palpable lumps that fluctuant with menses
 usually worst pre-menstrually
 objective data
 round, soft or firm, tense, mobile masses with well delineated borders
 usually tender
 usually bilateral
 multiple or single

Front 62

Common Abnormalities: fibroadenoma

Back 62

 Definition
 benign tumors composed of stromal and epithelial elements that represents a hyperplastic or proliferative process in a single terminal ductal unit
 pathophysiology
 may occur in girls and women of any age during their reproductive years
 after menopause, the tumors often regress
 subjective data
 painful lumps that do not fluctuate with the menstrual cycle
 may be asymptomatic with discovery on clinical breast examination or mammogram
 objective data
 round or discoid, firm, rubbery, mobile masses with well delineated borders
 usually nontender
 usually bilateral
 single; may be multiple
 biopsy often performed to rule out carcinoma

Front 63

Common Abnormalities: malignant breast tumor

Back 63

 Definition
 ductal carcinoma arises from the epithelial lining of ducts; lobular carcinoma originates in the glandular tissue of the lobules
 pathophysiology
 mutations in normal cells result in uncontrolled cell division and tumor formation; as the tumor grows and invade surrounding tissues, metastases occur through the length and vascular systems
 peak incidence between ages 40 and 75 years, with the majority of malignant breast tumors occurring in women older than 50 years
 subjective data
 painless lump; change in size, shape, or contour breasts
 axilla may be tender of lymph nodes involved
 may be asymptomatic with discovery on clinical breast examination or mammogram
 objective data
 may have palpable mass that is usually single; unilateral, a regular, or stellate in shape; poorly delineated borders; fixed; harder stone like; and nontender
 breasts may have dimpling, retraction, prominent vasculature
 skin may have peau d’orange or thickened appearance
 nipple may be inverted or deviate in position

Front 64

Common Abnormalities: fat necrosis

Back 64

 Definition
 benign breast pump occurs as inflammatory response to local injury
 pathophysiology
 necrotic fat in cellular the pre-become fibrotic and may contract into a scar
 subjective data
 history of trauma to depressed (including surgery)
 painless lump
 objective data
 firm, a regular mass, often appearing as an area of discoloration
 may mimic breast malignancy on clinical examination or breast imaging, requiring biopsy for diagnosis

Front 65

Common Abnormalities:  Intraductal papillomas

Back 65

 Definition
 benign tumors of the subareolar ducts that produce nipple discharge
 pathophysiology
 epithelial hyperplasia produces a wartlike tumor in a lactiferous duct
 2-3 cm in diameter
 may occur singly or in multiples
 subjective data
 spontaneous nipple discharge
 usually unilateral
 usually serous or bloody
 objective data
 single duct unilateral nipple discharge provoked on physical examination
 mass behind the nipple may or may not be present
 may need to be excised and examined to rule out malignancy

Front 66

Common Abnormalities: Paget disease

Back 66

 Pagets: On average, a woman may experience signs and symptoms for six to eight months before a diagnosis is made. [4]
 Paget's disease's symptoms may vary based on the stage of the disease. However, the main symptoms that can occur in Paget's disease include flaky or scaly skin on the nipple, straw-colored or bloody nipple discharge, skin and nipple changes in only one breast or the flattened nipples. Patients may also experience crusty, oozing or hardened skin resembling eczema, on the nipple, areola or both and fluctuating skin changes early on, making it appear as if the skin is healing on its own. Some patients complain of burning sensations on the nipples or breasts. These symptoms usually occur in more advanced stages, when serious destruction of the skin often prompts the patient to consult. Lumps or masses in the breast occur in 50% of the patients. [5] In more advanced stages, the disease may cause tingling, increased sensitivity and pain. [6]
 Definition
 surface manifestation of underlying ductal carcinoma
 subjective data
 crustiness of the nipple, areola, and surrounding skin
 objective data
 red, scaling, crusty patch on the nipple, areola, and surrounding skin
 maybe unilateral or bilateral
 appears eczematous but, unlike eczema, does not respond to steroids

Front 67

Common Abnormalities: gynecomastia

Back 67

 Definition
 breast enlargement in men
 pathophysiology
 result in increased body fat; hormone imbalance from puberty or aging; by testicular, pituitary, or hormone-secreting tumors; bio liver failure; or by a variety of medications including anabolic steroids, marijuana, some antihypertensives, some antipsychotics, or those containing estrogens or anti-androgens
 when testosterone levels are low relative to estrogen, breasts to grow larger and and more noticeable
 increased body fat, which in turn produces more estrogen, can cause breast enlargement
 subjective data
 breast enlargement
 relevant medication history
 objective data
 smooth, firm, mobile, tender disk of breast tissue located behind the areola
 usually nontender
 maybe unilateral or bilateral
 amount of breast tissue very; can be small overgrowth of breast tissue around the areola and nipple, the larger more "female"-looking breasts

Front 68

Common Abnormalities: galactorrhea

Back 68

 Definition
 lactation not associated with childbearing
 pathophysiology
 elevated levels of prolactin, resulting in milk production, occur as a result of disruption of the communication between the pituitary and hypothalamus glands
 common causes include pituitary secreting hormones, hypothalamic-pituitary disorders, systemic diseases, numerous medications and herbs, physiologic conditions, or local causes
 subjective data
 spontaneous nipple discharge, usually bilateral; usually serous or milky
 possible related medical history: amenorrhea, pregnancy, postabortion, hypothyroidism, Cushing's syndrome, chronic renal failure
 possible medication history: phenothiazines, tricyclic antidepressants, some antihypertensive agents, estrogens, H2 receptor blockers, marijuana, amphetamines, opiates
 possible physiologic history: suckling, stress, dehydration, exercise, nipple stimulation
 objective data
 multi-ductal nipple discharge may or may not be provoked on physical examination
 no mass

Front 69

Common abnormalities: Children

Back 69

 Gynecomastia
 Thelarche: breast development usually starts after 8 years old.
 Premature Thelarche
 Definition
 breast enlargement and girls before onset of puberty
 pathophysiology
 cause unknown
 breasts continue to enlarge slowly throughout childhood until full development is reached during adolescence
 subjective data
 breast enlargement
 objective data
 degree of enlargement varies from very slight to very full develops breasts
 usually occurs bilaterally
 other signs of sexual maturation may be absent

Front 70

Common abnormalities: Lactating women

Back 70

 Mastitis
 Definition
 inflammation and infection of the breast tissue
 pathophysiology
 most infections are staphylococcal, often Staphylococcus aureus
 most common in lactating women after milk is established, usually the second the third week after delivery; however, it may occur at any time
 abscess formation can result
 subjective data
 characterized by sudden onset of swelling, tenderness, redness, and heat in the breast
 usually accompanied by chills, fever
 objective data
 tender, hard breast mass, with an area of fluctuation, erythema, and heat
 may have discharge or pus (suppuration)
 underlying possibility abscess may impart a blue tinge to the skin

Front 71

Common abnormalities: older adults

Back 71

 Mammary duct ectasia
 Duct ectasia of the breast (or mammary duct ectasia) is a condition in which there is dilation of the lactiferous duct.[1] Mammary duct ectasia can mimic breast cancer. It is a disorder of premenopausal age. Signs of duct ectasia can include nipple retraction, inversion, pain[2], and sometimes bloody discharge. Histologically, dilation of the large duct is prominent. Pathogenesis may be a reaction to stagnant colostrum.
 Definition
 benign condition of the subareolar ducts that produce nipple discharge
 pathophysiology
 subareolar ducts become dilated and blocked with desquamating secretory epithelium, necrotic debris, and chronic inflammatory cells
 occurs most commonly in menopausal women
 subjective data
 spontaneously unilateral or bilateral nipple discharge
 often green or brown in color
 may be sticky
 objective data
 single or multi-ductal, unilateral or bilateral nipple discharge provoked and physical examination
 mass behind the nipple may or may not be present
 breast may or may not be tender
 nipple retraction may be present

Front 72

The largest amount of glandular breast tissue lies in the

Back 72

upper outer quadrant

Front 73

What breast structure drains milk from each lobe onto the surface of the nipple?

Back 73

lactiferous duct

Front 74

Milk production usually begins during which period

Back 74

2-4 days after delivery

Front 75

A 50-year-old woman presents as a new patient. Which finding in her personal and social history would increase her risk profile for developing breast cancer

Back 75

nulliparity

Front 76

To begin the clinical breast examination (CBE) for a man, ask him to

Back 76

sit with arms hanging at sides

Front 77

When conducting a clinical breast examination, the examiner should

Back 77

inspect each breast simulatenously

Front 78

Venous patterns on breasts are suggestive of pathology when they are

Back 78

unilateral

Front 79

In a woman complaining of a breast lump, it is most important to ask about

Back 79

its relationship to menses

Front 80

If your patient has nipple discharge, you will most likely need a:

Back 80

glass slide and fixative