1145 Breast & regional lymphatics

Created by mcostakis 

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What are the 4 quadrants of the breast?

Upper inner, Upper outer, lower inner, lower outer

What are Montgomrey's glands?

Sebaceous glands located on the areola

What is the tail of Spence?

The axillary portion of the breast

BSE

Breast Self Examination

CBE

Clinical Breast Examination

What are some problems or chief complaints about the breast/axillary?

Pain, tenderness, lumps, nipple discharge,

When asking problem based what do we always ask?

OLD CARTS

Gynecomastia

Enlargement of the male breasts

What are the causes of Gynecomastia?

Testerone disorders, Testicular cancer & other cancers, puberty, & obesity, or hormonal disorders.

Upon inspection what are some normal findings of the breast?

Symmetrical or slightly off, contour is smooth, convex, & even, even pigmentation, skin is smooth, abscess, erythemia, rash, venous patterns are bilaterally the same, Venous patterns may be pronounced in the obese, or pregnancy, & a rough/thickened skin.

What could marked asymmetry be an indication of?

Inflammation, or a growth

Unilateral rash could be an indication of what?

Paget's Disease a form of breast cancer

Unilateral venous patterns could be an indication of what?

Supply of blood to a malignancy

What does peau d' orange mean?

A term used to describe the orange-like texture of breasts that have edema

Upon inspection what are some abnormal findings of the breast?

Uneven venous patterns, marked asymmetry, dimpling, retraction, or bulging

Upon inspection what are some normal findings of the areola?

Color pink-black, Montgomrey's glands/tubercles, round or oval & hair.

Upon inspection what are some abnormal findings of the areola?

Oddly shaped, unsymmetrical, lesions, or changes in pigment.

Upon inspection what are some normal findings of the nipple?

Protruded, inverted, flat,

Upon inspection what are some abnormal findings of the nipple?

Point in different directions (malignancy), recent nipple inversion or retraction, discharge

What are Supernumerary nipples?

Nipples that resemble small pink or brown moles, they are sometimes found on the embryonic milk line.

Serous discharge

Yellowish: Normal

Serosanguineous

Straw colored: Carcinoma, Ductal ectasia, Bloody: intraductal papiloma, Ductal ectasia, Carcinoma,, prepartum women from vascular engorgement

Clear/watery

Carcinoma, medications

Milky

Pituitary adenoma, medications, Galactorrhea,

Purulent

Puss: Infection, Ductal ectasia

Multicolored

Green, Brown, or Grey: Ductal ectasia, carcinoma, Infection, & fibrocytic changes

Infections of the breast have what effect on the Axillary region?

Lymphatic drainage into the area

What are some abnormal findings when palpating the axillary?

Enlargement & tenderness of lymph nodes, hard masses, or fixed nodules.

What can be cause hard masses or fixed nodules in the axillary region?

Tumors, metastatic carcinoma, or Lymphoma.

What are the four methods of breast palpation?

Sweeping, Wedge, Circular, or the Vertical strip method

When palpating what should a normal breast fell like?

Firm, smooth, & elastic.

What are abnormal finding upon palpation of the breasts?

Loss of elasticity, & thick nipple tissue, & well as lumps.

Upon inspection of a mastectomy & axillary site what are we looking for?

Color changes, redness, rash, irritation, edema, thickening, lumps, muscle retraction, or Lymphedema

What is Lymphedema?

A collection of lymph in the interstitial spaces caused by the removal of lymph nodes.

What kind of palpation should be used on a patient with a mastectomy?

Sweeping or circular

surface anatomy

• Location of breasts on chest wall
• Axillary tail of Spence
• Nipple and areola

Internal anatomy: 3 tissues

1. Glandular tissue =
• lobes, lobules,& alveoli
• lactiferous ducts & sinuses
2. Fibrous tissue =
• suspensory ligaments or Cooper's ligaments
3. Adipose tissue

lymphatics: Axillary nodes (4)

- Central
- Pectoral (anterior)
- Subscapular (posterior)
- Lateral

Health history questions: Breast

- Pain
- Lump
- Discharge
- Rash (under arm as well)
- Swelling
- Trauma
- abnormal mammogram
- History of breast disease
- Surgery (implants, lumps)
- Self‐care behaviors
• Breast self‐examination • Last mammogram

Health history questions: Axilla

- Tenderness, lump, or swelling
- Rash

physical exam: breasts

• General appearance
• Skin
• Lymphatic drainage areas
• Nipple
• Maneuvers to screen for retraction

physical exam: Axillae

Inspect and Palpate
• Skin
• Palpation technique
• Lymph nodes

Palpate: Breasts

• Position
• Palpation patterns
• Expected findings
• Nipple
• Bimanual palpation or one handed

Patterns of breast exams (3)

1. circular
2. Wedge
3. Vertical strip
**Be sure to go up into the axilla (tail of Spence)

If a lump is present, note:

- Location = which quadrant
- Size
- Shape
- Consistency = soft, firm, etc.
- Mobility
- Distinctness = part of tissue or separate
- Nipple retraction
- Overlying skin = is it different than surrounding
- Tenderness
- Lymphadenopathy

abnormal findings

Signs of Retraction and Inflammation
• Dimpling
• Fixation
• Edema (peau d'orange)
• Deviation in nipple pointing
• Nipple retraction

Ductal ectasia

= benign disease → inflammation & dilation of subareolar ducts
• sticky nipple discharge that is commonly dark green or black. as progresses → burning, itching, edema

fibrocystic disease

= benign masses
• cysts that are palpable masses.
• round, well delineated, mobile and tender
• often fluctuate with menses

galactorrhea

=inappropriate lactation
• milky appearing discharge

mastitis

= inflammation of breast
• usually in one area of the breast
• red, edematous, tender, warm & hard
• axillary lymph nodes often enlarged & tender
• common in breast feeding

malignancy

• solitary, unilateral, non-tender lump, thickening or mass
• as tumor grows there may be asymmetry, discoloration, unilateral vein prominence, peak d'orange, ulceration, dimpling, puckering, retraction of skin
• borders irregular, nipple may be inverted

intraductal papilloma

= small, benign, warlike tumor in major ducts w/in 1-2cm of areolar edge
• a spontaneous bloody discharge from the nipples.
• sometimes a mass is palpated

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