Chapter 14: Breasts And Axillae

Question 1

Female physical exam

Answer 1

Inspect with patient seated and compare.
-Size, symmetry, contour, retractions or dimpling, skin color and texture, venous patterns, lesions, supernumerary nipples

Inspect both areolae and nipples.
-Shape, symmetry, color, smoothness, size, nipple inversion/eversion/retraction, supernumerary nipples

Reinspect breasts with patient.
-Arms extended over head or flexed behind the neck; hands pressed on hips with shoulder rolled forward; seated and leaning over; recumbent position

Perform a chest wall sweep.

Perform bimanual digital palpation.

Palpate for lymph nodes in axilla, down the arm to the
elbow, 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.

Question 2

Physical Exam Components: Males and Transgender Women

Answer 2

Inspect breasts.
-Symmetry, enlargement, surface characteristics

Inspect areolae and nipples.
-Shape, symmetry, color, smoothness, size, nipple inversion/eversion/retraction

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.

Question 3

breast HPI

Answer 3

Breast discomfort/pain
-Temporal sequence, relationship to menses, character, associated symptoms, contributory factors, medications, breast mass/lump, temporal sequence, symptoms, changes in lump, associated symptoms, medications

Nipple discharge
-Character, associated symptoms, associated factors, medications

Breast enlargement in men
-History of hyperthyroidism, testicular tumor, Klinefelter’s syndrome; medications; prostate cancer treatment; substance abuse

Question 4

PMH breast

Answer 4

Chronic breast diseases, genetic mutations (BRCA1/BRCA2), gender identity, previous related cancers, surgeries, risk factors for breast cancer, breast imaging history, menstrual history, pregnancy, lactation, menopause, hormonal medications, other medications

Question 5

FMH breasts

Answer 5

Breast cancer

Other cancers

Other breast disease in female and male relatives

Question 6

PMH/SMH breast

Answer 6

Age

Breast support while exercising

Caffeine

Breast self-awareness

Alcohol

Anabolic steroids, marijuana

Question 7

hx for preg and lactating pt

Answer 7

Pregnant patients
-Sensations, colostrum, supportive bra, breast-feeding

Lactating patients
-Hygiene practices, breast-feeding bra, nipples, associated problems, breast-feeding routine, breast milk pumping, breast-feeding cultural beliefs, food/environmental agents that affect breast milk, medications

Question 8

Hx older adult breasts

Answer 8

Skin irritation under pendulous breasts from tissue-to-tissue contact or from rubbing of brassiere; treatment
-Monilial dermatitis

Hormone therapy during or since menopause: name and dosage of medication; duration of therapy

Question 9

Breasts inspection

Answer 9

Patient seated with arms hanging loosely at the sides
-Size, symmetry, and contour
-Retractions or dimpling
-Skin color and texture
-Venous patterns
-Lesions

Areolae and nipples
-Shape, symmetry, color, smoothness, size, nipple inversion/eversion/retraction

Reinspect breasts in various seated positions.
-Arms extended over head or flexed behind neck
-Hands pressed on hips with shoulder rolled forward
-Seated and leaning forward from waist

Question 10

Breasts palpation

Answer 10

Patient in seated position
-Chest wall sweep. -Nodes should not be palpable.
-Bimanual digital palpation
-Lymph node palpation

Patient in supine position
-All areas of breast tissue for lumps or nodules
-If a breast mass is felt, note characteristics and palpate its dimensions, consistency, and mobility.
-Tail of Spence
-Nipples

Question 11

Infant physical exam

Answer 11

Breasts enlarge after birth in boys and girls.

Result of passively transferred maternal estrogen

May persist with breastfeeding

Question 12

Children and adolescent exam

Answer 12

Asymmetry in girls

Breast buds in boys

Gynecomastia in male adolescents

Question 13

Preg and lactating pt physical exam

Answer 13

Pregnant patients
-Increase in size; tenderness and tingling; enlarged erect nipples; vascular spiders and striae
-Colostrum
-Coarse nodularity of breast tissue
-Dilated subcutaneous veins

Lactating patients
-Engorgement
-Clogged milk ducts
-Irritated nipples

Question 14

Older adult inspection

Answer 14

Elongation or flattening

Hanging tissue

Smaller nipple size

Question 15

Palpation OA

Answer 15

Fine granular glandular tissue

Thickened inframammary ridge

Smaller, flatter nipples

Question 16

Inspect the Breast in the following positions:

Answer 16

Arms extended over head

Hands pressed against hips

Pressing hands together

Leaning forward from the waist

Chest Wall Sweep

Bimanual Digital Palpation

Palpation of Axilla for Lymph Nodes

Supine Palpation of the breast

Question 17

Variations Methods for Palpation:

Answer 17

Vertical Strips

Concentric circle palpation

Palpate out from center in Wedge Sections

Question 18

Breast abnormalities

Answer 18

Fibrocystic changes
Benign fluid-filled cyst formation caused by ductal enlargement

Fibroadenoma
Benign tumors composed of stromal and epithelial elements that represent a hyperplastic or proliferative process in a single terminal ductal unit

Malignant breast tumors
Ductal carcinoma arises from epithelial lining of ducts; lobular carcinoma originates in glandular tissue of the lobes.

Fat necrosis
Benign breast lump occurs as inflammatory response to local injury.

Intraductal papillomas/papillomatosis
Benign tumors of the subareolar ducts that produce nipple discharge

Duct ectasia
Benign condition of the subareolar ducts that produce nipple discharge

Galactorrhea
Lactation not associated with childbearing

Paget disease
Surface manifestation of underlying ductal carcinoma

Mastitis
Inflammation and infection of the breast tissue

Gynecomastia
Breast enlargement in males

Question 19

Breast abnormalities in children

Answer 19

Premature thelarche
-Breast enlargement in girls younger than 8 years of age
-Benign in the absence of pubic and axillary hair

Question 20

Clinical signs of breast cancer

Answer 20

Skin dimpling

Flattening of nipple

Question 21

Inspection of the breasts usually begins with the patient in which position?

Lateral
Sitting
Standing
Supine

Answer 21

ANS: B

Rationale: Inspection begins with the patient in a sitting position with arms hanging loosely at the sides.

Question 22

The anterior axillary lymph nodes would best be palpated at the:

Lateral axillary fold
Anterior axillary fold
Axilla close to the ribs
Posterior axillary fold

Answer 22

ANS: A

Rationale: The anterior axillary lymph nodes are located along the lower border of the pectoralis major, inside the lateral axillary fold.

Question 23

A peppering of nontender, nonsuppurative Montgomery tubercles is considered to be a:

Normal finding
Sign of cancer
Skin disease
Symptom of malnutrition

Answer 23

ANS: A

Rationale: Montgomery’s tubercles are the tiny bumps scattered around the areola and are regarded as an expected finding when they are nontender and have no purulent drainage.