H & P Breast Exam Flashcards
Communication Skills
-This portion of the physical examination requires constant communication with the patient
-Drape the patient carefully
-Warm hands before touching patient
-Explain each step of the exam
State what you are about to do before you do it
-Keep eye contact
-Watch for signs of discomfort
Breast/Axilla ROS
Breasts and axilla are examined together, comparing one side with the other.
Breast/Axilla ROS
Review of Systems Lumps Pain or discomfort Nipple discharge Self-examination
Sexual Maturity Rating
- Breast development = thelarche
- Sign of puberty
- Tanner stages I through V
- Menstruation begins at stage III or IV
- From stage II to menarche is about 2 years
- Breasts can develop at different rates in the same individual
Inspection
Contour Symmetry Vascular pattern Nipples Retraction Discharge Skin changes Piercings Skin characteristics Dimpling Edema Retraction Inflammation
By inspection, the breasts should
- Be symmetrical, full, rounded, smooth in all portions, without dimpling, retractions or masses
- Demonstrate a faint, even vascular pattern and striae
- Demonstrate everted nipples with even areola
- Demonstrate axillae with even color, without masses or rash
Inspection- Breast Location
Breast tissue can be located anywhere along milk lines, from the axilla to the groin
Polythelia
extra nipples
Polymastia
accessory breasts
Positions
Sitting
-Arms over head
Dimpling and retraction
-Hands pressed against hips
Dimpling and retraction
-Leaning forward
May reveal an asymmetry of the breast or nipple.
-Retraction of nipple and areola suggests cancerPalpation
-Palpation MUST be systematic and gentle, palpate men too
Note:
Tenderness
Nodules
Size and Mobility
Shape
Consistency
-Palpation should note
Firm tissue, without masses or lumps
Local areas without excessive warmth or tenderness
Nipples should not have discharge
Axillae should be smooth
Lymph nodes should not be palpablePalpation
-Palpate all four quadrants
-Several methods to use
-Do NOT omit the tail of Spence (axillary tail)
Many cancers discovered at this location
-Palpate under the areola and nipple
-Be aware of the infra-mammary ridge
Palpation Technique
- The middle three fingers are held together with the metacarpal-phalangeal joint slightly flexed
- Pads of the fingers are the examining surface
- Use light, medium, and deep palpation
Lymph Nodes
-Pectoral nodes
-Subscapular nodes
-Supraclavicular nodes
-Infraclavicular nodes
-Lateral nodes
-Central axillary nodes
-Not all lymphatics drain to the axilla
Some may drain to infraclavicular or mediastinal lymph nodes
The Axilla
Sitting position is preferable
Axilla Inspection
Rash, infection, unusual pigmentation, or nodules
palpation
Palpation
- Use right hand to exam the left axilla and vice versa
- Point fingers toward the midclavicle
- Press fingers toward the chest wall and slide them downward
- You should feel 1 or more soft, small (1cm suggest malignancy
- Check the supraclavicular, infraclavicular and epitrochlear nodes as well
Mastectomy or Breast Augmentation
- Inspect the mastectomy scar and axilla carefully
- Note masses or unusual nodularity
- Note color or signs of inflammation
- Lymphedema may be present in axilla and upper arm
Mastectomy or Breast Augmentation
Palpate gently along the scar-sensitive
- Use circular motion with 2 or 3 fingers
- Pay attention to the upper outer quadrant and axilla
- Note any enlargement of lymph nodes and signs of inflammation or infection
Male Breast Examination
-Brief but important
1% of breast cancer cases are male
Peak in frequency at age 71 years
Risk Factors: BRCA2 mutations, obesity, FHx, testicular conditions, work exposure to high temperatures and exhaust emissions
-Inspect the nipple and areola
If enlarged breast distinguish obesity vs. gynecomastia
Note nodules, swelling, discoloration, or ulceration
-Palpate the nipple and breast tissue
Note nodules
Breast Cancer Screening
-Screening Mammogram
Used to look for breast disease in women who appear to have no breast problems
-Diagnostic Mammogram
Used to find breast disease in women who have symptoms or who have found a lump or abnormal radiological changes
-A mammogram alone cannot prove that an area of concern is breast cancer
May need US and/or US-guided biopsy
Breast Cancer Screening
-Clinical breast examination
Q3 years, ages 20-39 years
Annually after age 40 years
-Breast self examination (BSE)
Q month beginning at age 20 years
Performed 5-7 days post onset of menses
-Mammography
Baseline at age 40 years, then Q1-2 years up to age 49 years
FHx of breast cancer, or those with increased risk may need mammogram, US, or MRI sooner
Annually from age 50-70 years
-MRI
>20% lifetime risk = MRI with mammogram annually
Breast Self Exam (BSE)
- 90% of breast cancers are found by women themselves.
- When women perform BSE properly and regularly, they can note any changes in their breasts and seek further evaluation.
- When women discover lumps in their breasts, and report these findings to their healthcare provider at a very early stage, surgery can save 70-80% of proven cases. - BSE should be performed Q month.
Breast Self Exam (BSE)
-Inspection before a mirror
Stand and face a mirror with arms relaxed at the sides or arms resting on hips; then turn to the right and left for a side view, looking for any flattening.
Bend forward from the waist with arms raised overhead
Stand straight with arms raised over head and move arms slowly up and down at the sides. Look for free movement of the breasts over the chest wall.
Press each arm firmly together at the chin level while elbows are raised to shoulder level.
-Palpate standing, sitting, or lying down
