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Physical Diagnosis > PD Breast and Axilla > Flashcards

PD Breast and Axilla Flashcards

1
Q

What muscles are superficial to the paired mammary glands on anterior chest?

A

Pectoralis major

Serratus anterior

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2
Q

What is the female breast composed of?

A

Glandular tissue
Fibrous tissue
Fat

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3
Q

How is the glandular tissue of the breast arranged?

A

15-20 lobes that radiate about the nipple

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4
Q

How are the lobes of the breast arranged?

A

Each lobe composed of 20-40 lobules

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5
Q

What do the lobules contain?

A

Milk producing cells that empty into lactiferous ducts

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6
Q

What is the function of the fibrous tissue?

A

Supports the breast

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7
Q

Where is fat located in the breast?

A

Subcutaneous, retromammary

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8
Q

What is the vascular supply to the breast?

A

Branches of internal mammary artery

Lateral thoracic artery

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9
Q

What are the five segments of the breast?

A

4 quadrants and a tail of Spence

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10
Q

Where does the greatest among of glandular tissue lie in the breast?

A

Upper outer quadrant

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11
Q

Each breast has a complex… network

A

Lymphatic

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12
Q

In the axillae, the mammary tissue is in direct contact with what structures?

A

Axillary lymph nodes

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13
Q

Montgomery tubercles

A

Small elevations on surface of areola
Sebaceous glands
Secrete lipoid material to protect nipples during nursing

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14
Q

What history questions do we ask patients about breasts?

A 
Mastalgia
Lumps/masses
Nipple discharge
Skin lesions
FHx of breast/ovarian cancer
Mammograms
Breast self exam
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15
Q

How do we prep the patient to be examined?

A 
Properly gowned patient
Unclothes from waste up
Warm, clean hands
Supine
Special maneuvers when lump or mass is detected
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16
Q

What do male practitioners need to do during a breast exam?

A

Males examining females should always have another female in the room

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17
Q

What are the positions the patient should be in for breast exam?

A

Sitting position with arms handing loosely at sides
Sitting, arms overhead/leaning forward
Sitting, hands on hips/pressed together

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18
Q

How does sitting with arms overhead or leaning forward affect the exam?

A

Position increases tension on suspensory ligaments and may help to accent any mass effect

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19
Q

How does sitting with hands on hips or pressed together affect the exam?

A

Maneuver contracts the pectorals muscles, lesions deeply adherent may manifest themselves

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20
Q

Inspection of breast

A 
Size
Skin
Texture
Symmetry
Venous patterns
Contour
Lesions
Supernumerary nipples
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21
Q

How do we need to position the breasts to examine them?

A

Make sure to lift each breast to inspect inferior aspect or folds

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22
Q

How do we compare breasts?

A

First compare left to right

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23
Q

What should we expect when comparing breasts?

A

Expect as a normal variant that one breast is slightly or even noticeably larger than the other

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24
Q

What are some breast abnormalities?

A

Dimpling
Retraction of skin surface or nipple
Peau d’orange

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25
Q

What kinds of patients would get infections under the breast?

A

Elderly
Obese
Diabetic
Immunocompromised

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26
Q

What does skin dimpling most likely indicate underneath?

A

Tumor

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27
Q

Nipple retraction

A

Common developmental anomaly results in nipple having crater-like depression
Harmless

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28
Q

What does appearance of nipple retraction after maturity arouse?

A

Appearance after maturity should arouse suspicion of underlying neoplasm or inflammatory disease

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29
Q

Peau d’orange

Cause

A

Appearance of skin that indicates edema of the breast caused by blocked lymphatic drainage
Often due to carcinoma
Skin looks thickened with enlarged pores and accentuated skin markings

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30
Q

Supernumerary nipples

A

Polythelia

One or more extra nipples located along embryonic mammary ride (milk line)

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31
Q

Palpation of breast

A 
Systemically palpate all 4 quadrants and tail of each breast, axillae, and supraclavicular regions
Hand and fingers flat
Press firmly
Small rotary motion
Don't lift hands off, slide
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32
Q

When would you use your thumbs for palpation of the breast?

A

Use thumbs only for discrete mass characterization

33
Q

How firmly should you palpate the breast?

A

Firmly, but no so firmly that breast compressed against rib cage

34
Q

Variety of methods of palpation of breast

A

Vertical
Circular
Wedge or radial

35
Q

How are patients positioned for palpation of breast?

A

Seated initially

Supine or slight incline to distribute breast tissue over chest wall and more easily compressed

36
Q

Palpation of areola / nipple

A

Make sure to palpate breast tissue deep to areola

Compress niple between thumb and index finger - inspect for drainage

37
Q

How do we characterize drainage of the areola?

A

Serous
Bloody
Pus

38
Q

More than 1/2 of breast cancers arise from what area of the breast?

A

Upper outer quadrant / Tail of Spence

39
Q

What other regions need to be palpated, besides the breast?

A

Axillae
Supraclavicular
For nodes - 1-2% of breast cancers only present as an enlarged LN

40
Q

Mass characterization

A 
Location
Size
Shape
Consistency
Tenderness
Mobility
Borders
Retraction
Overlying skin changes
Nipple discharge
41
Q

Common breast lesions

A 
Fibrocystic disease (mammary dysplasia)
Fibroadenoma
Breast carcinoma
Mastitis/abscess
Nipple discharge
Gynecomastia
42
Q

Inspection of nipple discharge

A 
Nature/consistency of discharge (clear, milky, pus, blood)
Association with mass or not
Unilateral/bilateral
Spontaneous or must be expressed
Relationship to menses
Any meds/estrogen
43
Q

Galactorrhea

A

Abnormal lactation (not associated with child bearing)

44
Q

Drug causes of galactorrhea

A 
Most commonly, drugs
Phenothiazines
TCA
Antihypertensive
Estrogen
45
Q

Intrinsic causes of galactorrhea

A 
Prolactin secreting tumors
Pituitary tumors
Hypothyroidism
Cushing syndrome
Hypoglycemia
46
Q

Gynecomastia

A

Enlargement of breast tissue in boys/men

47
Q

Causes of gynecomastia

A 
Puberty
Hormone imbalance
Testicular tumors
Pituitary tumors
Meds containing estrogens or steroids, antiHTN
Drugs like marijuana, alcohol, heroin
48
Q

What does gynecomastia feel like are where is it located?

A

Smooth, firm, mobile, tender disk of breast tissue located behind areola

49
Q

What is the most frequent disorder of the breast?

A

Fibrocystic disease

50
Q

Fibrocystic disease

A

Benign cyst formation caused by ductal enlargement
Rapid fluctuation in size
Lesions filled with fluid, usually bilateral and multiple

51
Q

What part of the menstrual cycle is fibrocystic disease associated with?

A

Long follicular or luteal phase

52
Q

Describe cysts of fibrocystic disease

A

Filled with fluid
Bilateral and multiple
Tender/painful with increase Sx premenstrually
Round, soft to firm and tense, mobile, no retractions or dimpling
No nipple discharge

53
Q

What age do patients usually present with fibrocystic disease?

A

30-50

54
Q

Fibroadenoma

A

Benign neoplasm accounts for majority of breast tumors in young women
Generally asymptomatic and do not change premenstrually

55
Q

Describe fibroadenomas

A 
Multiple
1-5 cm
Bilateral
Non tender/painless
Round or discoid with firm/rubbery consistency
Mobile with well delineated borders
No retraction
Often biopsied to rule out carcinoma
56
Q

Mastitis, breast abscess

A

Infection of the breast

Absces if pus pocket is present

57
Q

Cause of mastitis

A

Staph aureus

58
Q

Presentation of mastitis

A

Breast pain and redness in nursing mom

59
Q

PE findings with mastitis

A 
Erythema
Edema
Tenderness
Induration
Fluctuance
Fever/chills
Purulent nipple discharge
60
Q

What would we consider instead of mastitis in non lactating females?

A

Inflammatory breast Ca

61
Q

What is the second most common site of cancer in women?

A

Breast carcinoma

62
Q

Lifetime risk of breast Ca

A

In white women, 1 in 8/9

63
Q

What is the second most common cause of cancer death?

A

Breast carcinoma

64
Q

Peak age of breast carcinoma

A

40-60

65
Q

Most common initial symptom of breast carcinoma

A

Painless lump

66
Q

How does breast carcinoma metastasize?

A

Occur through lymphatic and vascular systems

67
Q

Breast carcinoma risk factors

A

White
Increasing age
Personal Hx
FHx, breast, ovarian, endometrial
Early menarche (before 12)
Late neopause (after 50)
Nulliparity
Late age at birth of first child (over 30)
Previous breast biopsies with benign disease
Genetic mutations of BRCA1 and 2
Estrogen replacement therapy after menopause (>4 years)

68
Q

Findings associated with breast carcinoma

A 
Mass or thickening in breast
Marked asymmetry
Prominent unilateral veins
Skin discolorations (erythema or ecchymoses)
Peau d'orange
Ulcerations
Dimpling, puckering, retraction of skin or areola
Fixed inversion or deviation of nipple
Crusting or erosion of nipple/areola
69
Q

What is the rationale for breast screening?

A

Not all breast carcinomas are palpable

70
Q

What are the qualities of palpable breast ca?

A 
Firm or hard
Non tender
Poorly defined borders
Accompanied by skin/nipple changes
Accompanied by discharge
71
Q

What kind of nipple discharge is indicative of breast carcinoma?

A

Bloody discharge

72
Q

Signs of advanced breast ca

A 
Erythema
Ulceration of skin
Large primary tumor
Fixation to chest wall
Enlargement or shrinkage/retraction of breast
Axillary or supraclavicular LAD
Ipsilateral arm edema
Distant mets
73
Q

What do recent studies suggest about BSE?

A

Monthly BSE do not impart any benefit to female patients towards decreases in breast cancer mortality

74
Q

Clinical breast examination by a health care provider should be done… over age of…

A

Yearly over age of 40

75
Q

American cancer society advocates … as a cancer screening tool in women over…

A

Yearly mammograms in women over 40

76
Q

Why is BSE done monthly?

A

So patient becomes familiar with the usual appearance and feel of her breasts - easier to notice changes

77
Q

When should a patient do a BSE?

A

2-3 days after menses, when breasts are least likely to be tender

78
Q

How do you perform a BSE?

A
  1. Stand before mirror and inspect both breasts for anything unusual
  2. Watching closely in mirror, clasp hands behind head and press hands forward
  3. Press hands firmly on hips and bow slightly toward mirror, pull shoulder elbows forward
  4. Raise left arm, use right hand to explore left breast firmly
  5. Gently squeeze nipple and look for discharge
  6. Repeat on right breast
  7. Repeat while lying down

Physical Diagnosis (10 decks)

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