Breasts and Regional Lymphatics

Question 1

Preparation of Breast examination

Answer 1

• Pt is sitting up facing the examiner
• Have the gown lifted to shoulders with inspection, for palpation when the pt is supine cover one breast examined and use a sensitive approach

Question 2

Inspect the Breast

Answer 2

General Appearance
- Note symmetry of size and shape
- Slight asymmetry in size (The left breast is bigger than the right breast)

Skin
- Smooth and even color
- Note any redness, bulging, dimpling, skin lesions, and focal vascular pattern. No edema present (pig skin or orange-peel look Peau d’orange)
- The blue vascular network is normally visible during pregnancy
- Pale linear striae or stretch marks often follow pregnancy

Lymphatic Drainage Areas
- Observe axillary and supraclavicular regions
- Note any bulging, discoloration, and edema

Nipple
- Should be symmetrical on the same plane as the two breasts
- Nipples should protrude, although some are flat and inverted
- Normal nipple inversion may be unilateral or bilateral and be pulled out
- Note for dry scaling, any fissure or ulceration, and bleeding or other discharge

Question 3

Maneuvers to Screen for Retraction

Answer 3

• Direct the woman to change position while checking the breast for skin retraction
• First, ask the pt to lift her arms above her head breast should move up symmetrically
• Second then, ask her to push her hands onto her hips
• Lastly, push her two palms together
• The maneuvers contract the pectoralis major muscle that will contract the breast slightly

Question 4

Inspect and Palpate the Axillae

Answer 4

• Examine the pt while sitting down
• Inspect the skin noting for rash or infection
• Lifts woman’s arm and support it palpate left axilla for tenderness or palpable lymph nodes
• Reach fingers high into the axilla and move them firmly down in four directions:
  
  • Down the chest wall in a line from the middle of the axilla
  • Anterior border of the axilla
  • Posterior border
  • Inner aspect of the upper arm
  • Should not be palpable but will feel a small tender node in the central group

Question 5

Palpation of the Breast

Answer 5

• Pt should be in a supine position
• Get a pad to be placed on the side to be palpated and raise her arm over her head
• Use the first three pads of fingers and use a vertical strip pattern to detect any lumps or breast mass
  - Palpate the four breast quadrants
• Using the vertical strip examine the tail of Spence high into the Axilla in each woman
• Breast tissue should feel firm, smooth, and elastic
• May feel a firm transverse ridge of compressed tissue in the lower quadrants
  -The inframammary ridge is noticeable in large breast
• Women wt large pendulous breasts, palpate using a bimanual technique
  
  • Pt should be sitting up and leaning forward
  • Support the inferior part of the breast wt one hand and use the other hand to palpate the breast tissue

Question 6

Palpation of the nipple

Answer 6

• Noting for induration or subareolar mass
• Using the thumb and the forefinger, gently depress the nipple
  
  • Should move inward easily
• if pt states they have nipple discharge squeeze around areola in different directions, if discharge comes out
  
  • Note consistency and color

Question 7

Characteristic of a Lump

Answer 7

• Location: use the breast as a clock face, describe distance from nipple in cm (7:00 position, 2 cm from nipple)
• Size: judge in cm (width x length x thickness) Shape: oval, circle, lobulated, indistinct
• Consistency: hard, firm, soft
• Movable: freely moving or fixed Distinctiveness: solitary or multiple
• Nipple: is lump displaced or retracted
• Skin over lump: dimpled, retracted, erythematous
• Tenderness: tender to palpate
• Lymphadenopathy: whether any regional lymph nodes are palpable

Question 8

Breast self Examination for Women

Answer 8

• Suggest the pt to inspect their breast in front of a mirror while disrobed to the waist
• Encourage them to learn how their breast feel while in the shower, where the soap and water assist the palpation, and while lying supine so that the breast tissue is flattened
• Encourage to palpate their own breast while you are there to assess their technique

Question 9

Breast Examination in Men

Answer 9

• Inspect the Chest wall, noting for the skin surface and any lumps or swelling
• Palpate the nipple area for any lump or tissue enlargement
  - It should feel even with no nodules
• Palpate the axillary lymph nodes
  
  • Down the chest wall in a line from the middle of the axilla
  • Anterior border of the axilla
  • Posterior border
  • Inner aspect of the upper arm
  • Should not be palpable but will feel a small tender node in the central group