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Internal Medicine > OHCEPS - The Breast > Flashcards

OHCEPS - The Breast Flashcards

1
Q

Anatomic location of the breast?

A

Extend from the 2nd to the 6th ribs and transversely from the lateral border of the sternum to the midaxillary line.

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2
Q

Lymphatic drainage of the breast?

A

Medial –> To the internal mammary nodes.

Central/Lateral –> To the axillary lymph nodes which are arranged into 5 groups.

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3
Q

Normal breast changes - Puberty?

A

During adolescence, estrogen promotes the development of the mammary ducts and distribution of fatty tissue while progesterone induces alveolar growth.

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4
Q

Normal breast changes - The menstrual cycle?

A

Towards the 2nd half of the menstrual cycle, after ovulation, the breasts often become tender and swollen.
They return to their “resting” state after menstruation.

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5
Q

Normal breast changes - Pregnancy?

A

High levels of placental estrogen, progesterone, and prolactin promote mammary growth in preparation for milk production.

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6
Q

Normal breast changes - Postnatal?

A

The sharply declining levels of estrogen and progesterone permit prolactin to stimulate the alveoli and milk produced. Suckling stimuli incr. secretion of prolactin as well as releasing oxytocin which stimulates myoepithelial cells to contract.

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7
Q

Normal breast changes - Menopause?

A

The breasts become softer, more homogenous and undergo involutional changes including a decr. in size, atrophy of secretory portions, and some atrophy of the ducts.

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8
Q

Important symptoms - First steps?

A
  1. Establish a menstrual history.
  2. Determine date of last period of menstruation
  3. It is important to note that pre-existing disease in the breast is likely to become more noticeable during the 2nd half of the menstrual cycle - lumps often get bigger or become more easily palpable.
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9
Q

Important symptoms - Breast pain (mastalgia)?

A

Establish everything as for any pain. Also ask:

  1. Unilateral/Bilateral?
  2. Heat/Redness at the site?
  3. Other visible skin changes?
  4. Pain is cyclical/constant - and is it related to menstruation?
  5. Is there a history of any previous similar episodes?
  6. Breastfeeding?
  7. Any hormonal therapy?
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10
Q

MCC of mastalgia in premenopausal women?

A

Hormone-dependent change. Other benign causes include mastitis and abscesses.

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11
Q

What percentage of breast cancers present with mastalgia as the sole symptom?

A

1/100

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12
Q

Important causes of nipple discharge?

A
  1. Ductal ectasia
  2. Papilloma
  3. Carcinoma
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13
Q

Nipple discharge - What to ask about?

A
  1. Discharge is true milk or some other substance?
  2. Discharge color (clear, white, yellow, blood-stained?)
  3. Spontaneous/Non spontaneous discharge?
  4. Bilateral/Unilateral?
  5. Any changes in the appearance of the nipple or areola?
  6. Mastalgia?
  7. Any breast lumps?
  8. Periareola abscesses or fistulae indicating periductal mastitis.
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14
Q

Periductal mastitis - features?

A
  1. This is closely linked to smoking in young women. Periductal mastitis is also associated with hydradenitis suppuritiva.
  2. Ask about abscess elsewhere eg axilla and groins.
  3. Symptoms are recurrent.
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15
Q

How to take a menstrual history?

A
  1. Age of first menses
  2. Usual time between menstruations
  3. Usual duration of menstruation
  4. Usual quantity of menstruation
  5. Age of menopause (if applicable)
  6. Number of pregnancies
  7. Previous history of breast-feeding
  8. The date of the beginning of the last menstrual period
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16
Q

Breast lumps - Important to establish what?

A
  1. When the lump was first noticed?
  2. Whether the lump has remained the same size or enlarged?
  3. Whether the size of the lump changes according to the menstrual cycle.
  4. Is there any pain?
  5. Any local skin changes?
  6. Is there a history of breast lumps - previous biopsies, diagnoses, operations.
  7. Full system enquiry –> Loss of weight, appetite, fatigue + metastatic spread (dyspnea, bone pain etc).
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17
Q

Breast lumps - Age?

A

A good clue as to the likely diagnosis of a lump is the age of the patient:
20-30 –> Fibroadenomas
30-50 –> Cysts
>50 –> Cancer

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18
Q

The male breast - Gynecomastia?

A
  1. Enlargement of the male breast tissue which should not normally be palpable –> There is an incr. in the ductal and connective tissue.
  2. Common occurrence in adolescents and the elderly. Also in obese due to increased adipose tissue.
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19
Q

Important drugs causing gynecomastia?

A
  1. Estrogen receptor binders
  2. Digoxin
  3. Marijuana
  4. Spironolactone
  5. Cimetidine
  6. Hormone treatment for prostate cancer
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20
Q

Gynecomastia - What else to examine?

A

Signs of:

  1. Hypopituitarism
  2. Chronic liver disease
  3. Thyrotoxicosis
  4. Examination of the genitalia
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21
Q

Breast cancer in male?

A
  1. 100:1 female/male
  2. Appearance and pathology similar to female.
  3. MC presentation is a hard, painless lump fixed to the skin or chest wall followed by nipple discharge.
22
Q

Risk factors for breast cancer in females?

A
  1. Advancing age
  2. Breast cancer in a 1st degree relative
  3. BRCA genes
  4. Previous cancer in the other breast
  5. Early menarche (55yr)
  6. Nulliparity
  7. No previous breastfeeding
  8. Previous radiotherapy - eg mantle radiotherapy for Hodgkin’s.
  9. Oral contraceptive pill or HRT
23
Q

Some causes of breast lumps?

A
  1. Cyst
  2. Fibroadenoma
  3. Carcinoma
  4. Fat necrosis
  5. Hamartoma
  6. Lipoma
  7. Epidermoid cyst
  8. Cystosarcoma
24
Q

Inspection of the breast - General inspection?

A

Stand in front of the patient and observe both breasts, noting:

  1. Size
  2. Symmetry
  3. Contour
  4. Colour
  5. Scars
  6. Venous pattern on the skin
  7. Any dimpling or tethering of the skin
  8. Ulceration
  9. Skin texture: eg any visible nodularity
25
Q

Nipples - Note:

A
  1. Symmetry
  2. Everted, flat, inverted
  3. Scale –> may indicate eczema or Paget’s disease of the breast
  4. Associated with any discharge
  5. If abnormalities present, make sure to ask if these are a recent or a long-standing appearance
  6. Make note of additional nipples along the mammary line.
26
Q

Single duct discharge indicates?

A

Papilloma or cancer.

27
Q

Multiple duct discharge at the nipple suggests?

A

Duct ectasia

28
Q

Inspection of the breast - Axillae?

A
  1. Ask the patient to place her hands on her head and repeat the inspection process.
  2. Pay particular attention to any symmetry or dimpling that is now evident.
  3. Examine the axillae for masses or color image.
29
Q

Inspection of the breast - Maneuvers?

A

Finally, dimpling or fixation can be further accentuated by asking the patient to:

  1. Lean forward while sitting
  2. Rest her hands on her hips
  3. Press her hands against her hips (“pectoral contraction maneuver”).
30
Q

Palpation of the breast - Before you start?

A
  1. Palpation of the breast should be performed with the patient lying supine on the couch.
  2. INITIALLY, the patient should have her hands by her sides.
  3. Examination of the UPPER-OUTER quadrant is best performed with the hand on the side to be examined placed behind her head.
31
Q

Palpation - What must be asked first?

A
  1. Ask the patient if there is any pain or tenderness - examine that area last.
  2. Also ask her to tell you if you cause any pain during the examination.
  3. You should begin the examination on the asymptomatic side, allowing you to determine the texture of the normal breast first.
  4. Ask the patient to point out any areas of tenderness and come to these last.
32
Q

Palpation of the breast - Steps?

A
  1. Should be performed by keeping the hand flat and gently rolling the substance of the breast against the underlying chest wall.
  2. Most breasts feel “lumpy” if pinched.
  3. Proceed in a systematic way to ensure that the whole breast is examined.
  4. Do not forget to examine the axillary tail of Spence stretching from the upper-outer quadrant to the axilla.
33
Q

Palpation of the breast - Lumps?

A
  1. If you feel a lump, describe it (position, color, shape, size, tenderness etc).
  2. Next ascertain its relations to the overlying skin and underlying muscle.
  3. You must decide whether you are feeling a lump or a lumpy area.
34
Q

Lumps - Tethering?

A
  1. A lump may be described as tethered to the skin if it can be moved independently of the skin for a limited distance but pulls on the skin if moved further.
  2. Tethering implies that an underlying lesion has infiltrated Cooper’s ligament which pass from the skin through the subcutaneous fat.
  3. Tethering may involve the skin itself with cancers or abscesses.
35
Q

Lumps - Tethering - Inspection?

A

On inspection at rest, there may be puckering of the skin surface (as if being pulled from within) or there may be no visible abnormality.

36
Q

Lumps - Tethering - How to demonstrate?

A
  1. Move the lump from side to side and look for skin dimpling at the extremes of movement.
  2. Ask the patient to lean forwards while sitting.
  3. Ask the patient to raise her arms above the head.
37
Q

Lumps - Skin fixation?

A
  1. This is caused by direct, continuous infiltration of the skin by the underlying disease.
  2. The lump and the skin overlying it cannot be moved independently.
  3. It is on a continuum with skin tethering.
  4. It may be associated with some changes of skin texture.
38
Q

The relation of the lump to a muscle?

A
  1. The lump may be tethered or fixed to the underlying muscle (eg pectoralis major).
  2. Lumps that are attached to the underlying muscle can be moved to some degree if the muscle is relaxed but are less mobile if the muscle is tensed.
39
Q

How to examine the relation of a lump to the muscle?

A
  1. Ask the patient to rest her hand on her hip with the arm relaxed.
  2. Hold the lump between your thumb and forefingers and estimate its mobility by moving it in 2 planes at right angles to each other (up/down, left/right).
  3. Ask the patient to press her hand against her hip causing contraction of pectoralis major. Repeat the mobility exercise.
40
Q

Lumps - Immobile lump?

A

If a lump is immobile in all situations, it may have spread to involve the bony chest wall (eg in the upper half of the breast or axilla).

41
Q

Palpation of the breast - Nipple?

A
  1. If the patient complains of nipple discharge, ask her to gently squeeze and express any discharge, noting color, presence of blood, smell.
  2. Milky, serous, or green-brown discharges are almost always benign.
  3. A bloody discharge may indicate neoplasia (papilloma or cancer).
42
Q

Examination of the lymph nodes?

A
  1. Support the patient’s arm.
  2. When examining the right axilla, abduct the patient’s right arm gently and support it at the wrist with your right hand while examining the axilla with your left hand.
  3. Examine the main sets of axillary nodes, including:
    a. Central
    b. Lateral
    c. Medial (pectoral)
    d. Infraclavicular
    e. Supraclavicular
    f. Apical
  4. Remember also to palpate for lymph nodes in the lower deep cervical lymph chain at the same time as the supraclavicular nodes.
43
Q

Examining beyond the breast - Rest of the body?

A

If cancer is suspected, is worth performing a full general examination keeping in mind the common sites of metastasis of breast cancer.
–> Examine especially –> Lungs, liver, skin, skeleton, CNS.

44
Q

Important presentation - Fibroadenoma?

A
  1. Painless
  2. Solid
  3. Mobile
  4. Well-circumscribed rounded breast mass
  5. Smooth, bosselated surface and rubbery consistency.
  6. May be multiple and bilateral with no axillary lymphadenopathy.
  7. Large fibroadenomas may be found in teens.
45
Q

Important presenting patterns - Breast abscess?

A
  1. Mainly during the childbearing years and are often associated with trauma to the nipple during breast feeding.
  2. Present with a painful, spherical lump with surrounding edema.
  3. Often shows additional signs of inflammation (hot, red).
  4. Patients may have constitutional symptoms –> malaise, night sweats, hot flushes and rigors.
46
Q

Important presenting patterns - Recurrent and chronic breast abscesses?

A

Most of them occur in association with duct ectasia or periductal mastitis.
–> Associated periductal fibrosis can often led to nipple retraction.

47
Q

Important presenting patterns - Abnormal nipple and areola?

A
  1. Diseases of the nipple are important because they must be differentiated from malignancy and cause concern to the patients.
  2. Unilateral retraction or distortion of a nipple is a common sign of breast carcinoma - as is blood-stained nipple discharge (papilloma or carcinoma.
  3. Unilateral red, crusted and scaling areola suggests an underlying carcinoma (Paget’s disease of the breast) or, more commonly, eczema –> Ask the patient if she has eczema at other sites and examine appropriately.
48
Q

Important presenting patterns - Breast cancer - Presenting symptoms related to the primary lesion?

A
  1. Palpable mass
  2. Pain (1% of cancers presents with mastalgia only)
  3. Nipple discharge, retraction, or rash.
  4. Dimpling of the breast tissue
  5. Local edema
49
Q

Important presenting patterns - Breast cancer - Presenting symptoms related to the effects of secondary spread?

A
  1. Arm swelling (lymphatic or venous obstruction)
  2. Backache (skeletal infiltration)
  3. Malaise
  4. Loss of weight
  5. Dyspnea
  6. Cough
  7. Nodule in skin
  8. Jaundice
  9. Mental changes
  10. Fits/Seizures
  11. Symptoms of hypercalcemia (thirst)
50
Q

What are the mammary glands?

A

Highly developed apocrine sweat glands.

Internal Medicine (107 decks)

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