Test 3: Breast and Axilla Assessment Flashcards
Redness and warmth indications:
Inflammation or infection
Mastitis
Abscess
Inflammatory CA
Risk Factors for Breast CA
Age - Older, more likely
Gender - Female more likely
Risk Factors: Personal Family History
- Family member with history of breast CA
- Ashkenazi Jewish Heritage
- African American with breast cancer before 35
- Man in family with breast CA
Risk Factor: Estrogen Exposure
- First period before 13
- Entering menopause after 51
- Using estrogen replacement for more than 5 years
Risk Factors: General
- Never been pregnant or pregnancy after 30
- No breastfeeding
- Higher education and socioeconomic group
- Taller height
- Sitting (more than 6 hours a day)
- Dense Breasts
- High waist-hip ratio
- High fat diet
- Radiation exposure
Mortality Risk Factors
- Poor screening
* Even though breast CA more common in women, the mortality rate is higher in men
Breast Discomfort
Note pattern, onset, duration,severity, character, associated S&S, and contributing and relieving factors
Swelling or lumps
Location, size, changes in surface of breast, mobility, time 1st noted, changes in menses, assoc. S&S
Discharge
Color, consistency, amount, odor, onset/injuries, date of last pregnancy/birth, breastfeeding history, medication (contraceptives may produce a clear discharge)
Equipment needed for PE
Gloves
Small pillow
cm ruler
Glass slide and fixative (for possible discharge)
Skin: Normal
- Pink to dark brown areola/nipple
- Hyper-pigmentation normal if smooth and symmetrical
- Even color
Skin: Abnormal
Redness
Texture (peau d’orange) - Breast looks like orange peel due to swelling
*Focal areas of dark skin or discoloration
Vascularity: Normal
- Symmetrical, diffuse pattern
- Not prominent
- May be easy to see in pregnant or obese women
Vascularity: Abnormal
- Focal, unilateral area of increased venous prominence
* Engorged vessels may indicate feeding a tumor
Moles
Common, ask if recent changes or changes in size and color
Striae
Stretch marks
Normal
Supernumerary Nipple
Accessory nipple
- Occurs along milk like ( like dogs)
- Can grow breast tissue, be painful, change in menses
- Increased risk of breast cancer in this tissue
Breast Size and Symmetry: Normal
Approximate in size and basically symmetrical
Breast Size and Symmetry: Abnormal
*Grossly different in size
Gynecomastia
Large breasts in men or infants
- can secrete milk
- hard disc under nipples
Gynecomastia Causes
- Puberty
- hormone imbalance due to tumor on pituitary, prostate and testes
- Alcohol abuse
- Meds (estrogen, depression, steroid abuse)
- Leukemia
- Cirrhosis of the Liver
Contour of Breast: Normal
Smooth, even, rounded, convex, uninterrupted surface
Contour of Breast: Abnormal
- Retraction (inverted nipple)
- Dimpling (depression on skin)
- Flat on one side - breast do not look round
- Obvious Bulges
Hair: Normal
Women may have dark curly hair on areola
Male may have dense mass of chest hair
Hair: Abnormal
If women have male hair pattern
Nipple Color: Normal
Darker than surrounding breast
May darken during pregnancy
Nipple Color: Abnormal
Reddened or gross asymmetry
Nipple Size and Shape: Normal
Symmetrical,roung,wrinkled
Montgomery Tubercles
Small, elevated sebaceous glands on nipple
Secrete protective lipid material during lactation
Normal
Nipple Size and Shape: Abnormal
- Inverted,unless if been inverted since puberty
* Nipple different color than areola
Paget’s Disease
- CA of mammary gland
- Crusting, cracking, scaling, discharge, rash, ulceration (esp. unilateral)
- Shape may be unilateral (gross asymmetry)
Direction of Nipples: Normal
- On nipple line
- Point outward and downward (laterally)
- Symmetrical
Direction of Nipples: Abnormal
- Not on nipple line
* Asymmetrical
Discharge: Normal
- No discharge
- Can have clear discharge with mechanical manipulation
- Pregnant or lactating women may have a milky discharge
Discharge: Abnormal
- Milky, watery, purulent, serous, bloody
* Caused by drugs (estrogen,, anti-HTN, anti-depressants), endocrine disorders, CA, benign breast lesions
Inspection Positions
- Raise arms overhead
- Press hands together
- Look for changes in appearance, especially retractions, dimpling, or fixation of breasts, and uneven nipple line
- Press into hips
- For women with large pendulous breast, also with arms stretched out in front, we want the breasts to hang free and away from the body
Lateral (Brachial) Node
The node goes up the arm from inside the axilla
Along the humerus, inside the upper arm
Central Axillary Node
Way deep into the center of the underarm
High up in the middle of the axilla, over the ribs and serratus anterior muscle
Subscapular Node
Towards the back behind the axillary line. Can feel the muscle mass that goes towards the back
Along the lateral edge of the scapula, deep in the posteror axillary fold
Anterior Axillary (Pectoral)
- Located on the muscle that is under the breast
* Along the lateral edge of the pectorals major, just inside the anterior axillary fold
Palpation of Breasts
- Palpate the breasts normally in a sitting position
- If pt. reports a mass, do that breast second so we can have a control with the normal breast
- If woman has large breasts use the bi-manual technique with dominant hand on top
- Remember to palpate the Tail of Spence, using the 3 middle fingles (flat part)
- Palpate the nipple itself and squeeze the nipple in all four directions
Palpation Findings
- Most masses and CA occur in the Tail of Spence in the UOQ
- Normal breast consistency varies (lumpy,granular, non-uniform, nodular)
- Note any mass or thickening that is different form other tissue or that is a change
Location of Breast Mass
- Note which breast, right or left
- Quadrant
- Time designation
- cm from nipple
Shape of Breast Mass
round, ovoid, irregular, (confluent), multiple lesions together
Consistency of Breast Mass
soft
hard
rubbery
solid
Discreteness of Breast Mass
Sharp
well defined borders
irregular
difficult to find borders
Mobility
Freely movable (usually benign) Fixed (bad sign)
Depth of mass
Superficial
midlevel
deep against ribs
Malignant tumor
Spread out, irregular shaped
Fixed
Grabbing onto other structures (causing dimplint)
Benign abscess
Confluent, not fixed, smooth
Fibrocystic Disease
Very Round lumps
Very cystic (fluid flilled)
Discrete
Can be painful and have changes with menses
Intraductal Papilloma
Usually cause bleeding in milk duct
Typically not malignant
Mastectomy Exam
Could still have residual cancer tissue that can cause growth
Want to look at scar itself for dimpling, redness, buldges
MRI
Magnetic Resonance Imaging
PET Scan
Positron Emission Tomography
- Medical imaging that uses radioactive chemical injected into tissue and absorbed by specific kinds of body tissue, such as CA
- Pts. with breast implants and dense breasts may benefit from PET scans
Sentinel Node Biopsy
- A new test being used, uses PET scanning
- Aims to accurately stage the axillary or other node involvement
- Technique used to identify the first nodes that tumor drains to
- Used to see where the cancer has spread to and what stage the cancer is in
Fibrocystic: Age Occurrence Location Nipple Discharge Pain or Tenderness Number Shape Consistency Mobility Retraction Borders Variations w/ menses
age:20-49
occurrence: usually bilateral
Location: UOQ
Nipple discharge: no
Pain or tenderness: yes
Number: Multiples or single
Shape:round
Consistency: soft to firm or tense
Mobility: mobile
Retraction: Absent
Borders: well delineated
Variations with menses: yes
Fibroadenoma Age Occurrence Nipple Discharge Pain or tenderness Number Shape Consistency Mobility Retraction Borders Variations with menses
Age: 15-55 Occurrence: usually bilateral Location: no specific Nipple discharge: no Pain or tenderness: no Number: single; sometimes multiple Shape: rounded or discoid consistency: firm, rubbery Mobility: mobile Retraction: absent Borders: well delineated Variations with menses: no
Cancer Age Occurrence Location Nipple Discharge Pain or tenderness Number Shape Consistency Mobility Retraction Borders Variations with menses
Age: 30-80 Occurrence - Usually unilateral Location: 48% in UOQ but also any part Nipple discharge: bloody or clear if present Pain or tenderness: usually no Number: shape Shape: irregular or stellate Consistency: hard, stone-like Mobility: fixed Retraction: often present Borders: poorly delineated; irregular Variations with menses: no
Cooper Ligaments
Fibrous connective tissue extending vertically form the skin surface to attach on chest wall muscle. These support the breast tissue
Colostrum
Thick, yellow fluid that is the precursor to breast milk
Contains no fat
Rich in antibodies to protect the newborn against infection
