Clinical assessment of breast

clinical examination of breast

1. Clinical Examination of Breast

2. ANATOMY OF BREAST EXTERNAL ANATOMY SHAPE AND SIZE :considerable individual variation BASE : vertically - from 2nd to 6th rib in midclavicular line horizontally - from the midline of the sternum almost to the midaxillary line superolaterally - extends as the axillary tail of spence through the foramen of langer

3. THE AREOLA :pigmented circular area of skin around the base of the nipple It contains a number of subcutaneous glands which enlarge during pregnancy and are called tubercles of Montgomery THE NIPPLE {papilla mammaria }:cylindrical or conical structure projecting from the center of the areola It contains an elaborate subcutaneous network of of smooth muscle cells and elastic fibers

4. BREAST GLANDS Each breast has 8 to 10 sections ( lobes ) arranged like the petals of daisy Inside each lobe are many smaller structures called lobules At the end of each lobule are tiny sacs ( bulbs ) that can produce milk

5. ARTERIAL SUPPLY It is supplied by: Lateral thoracic branch of 2nd part of axillary artery Medial mammary branches of internal thoracic artery Superior thoracic branch of axillary artery Lateral branches of 2nd,3rd,4th posterior intercostal arteries

6. VENOUS DRAINAGE Circular venosus -an anastamotic venous plexus deep to the areola at the base of the nipple. From this plexus two sets of veins are formed : 1.superficial set- ends in internal thoracic vein 2.deep set - ends in internal thoracic , axillary and post intercostal veins

7. LYMPHATIC DRAINAGE 5 Groups: ANTERIOR (PECTORAL) SET : Situated along the lateral thoracic vein under the ant axillary fold,they lie mainly on the 3rd rib POSTERIOR (SCAPULAR) SET: Lies on the post axillary fold in relation to the subscapular vessels LATERAL (AXILLARY VEIN) SET: Along the upper part of humerus in relation to the axillary vein CENTRAL SET : Situated in the fat of the upper Axilla . APICAL or INFRACLAVICULAR SET: Lie deep to the clavipectoral fascia along the axillary vesels

8. History Lump – duration,onset,rate of growth Pain Fever Discharge from nipple Retraction of nipple Trauma Loss of weight/appetite

9. History Swelling elsewhere Related to metastasis- bone pain, jaundice ,cough with hemoptysis, Similar episodes Smoking Alcoholism Diet habits(high fat diet) Breast feeding Drug intake

10. History - CA risk factors •  A ge: older • History : family, prior dz •  A bortion •  L ate menopause •  O bese •  N ulliparity •  E arly menarche A History ALONE

11. Pt removes upper body clothing Expose/ inspect the opposite side so can compare for asymmetry . Expose

12. Ask pt. if Tenderness before start touching them. Warm your hands Tenderness

13. Introduce yourself to the patient Ask Permission to perform the examination Assure privacy ask for chaperone to be present Explain what you want to do Expose the patient adequately Position the patient correctly If sores visible,wear gloves .

14. Methods of Inspection Sitting position,arms at sides Arms overhead

15. Arms pressing on hips Leaning forward

16. Inspection Position : Sitting with arms by side Symmetry Any mass Skin Ulcer

17. skin Skin retraction Dimpling

18. skin Redness Peau d'orange (ca) Veins: congestion mastitis Inflammatory ca

19. Nipples Nipple number, position Inversion retraction; (fibrosis, CA, normal) Slit like

20. Nipples Red, bleeding (Paget's dz of nipple). Discharge

21. Ask patient to raise arms and place hands behind head Change in a mass's relative position. Nipple or skin tethering

22. Inspect whole skin Raise the breast to inspect the undermined skin.

23. Inspect the axilla Examine axilla while pt's arms are raised; axillary tail axillary LNs any mass, ulcer Edema,nodules Cancer en cuirase

24. Pt. pushes hands on hips. Look for: • Dimpling. • Fixation. Large breasts: pt. leans forward Hands on knees Ask patient to put hands on hips and push inwards flexes pectorals Again look for contour of breast

25. Palpation - Use fingerpads of middle 3 fingers -Palpation should not elicit pain -Consistency is highly variable

26. Sitting position First examine sitting Examine ‘normal’ side first Place hand behind head One quadrant at a time

27. Supine position Spreads the breast more evenly across chest Examine lying down Use one or two hands to elicit lumps If felt define lump with fingertips See Examining A Mass

28. Press breast against chest wall Rolling fingers in small, circular motions. Press lightly for superficial layers Medium pressure for middle layer Firmer pressure for deepest layers Start at sternoclavicular junction. Move in overlapping vertical strips until all 4 breast quadrants are covered.

29. Evaluation of Breast Mass Characteristics Location Size Shape Number Consistency Definition Mobility Tenderness Erythema Dimpling or retraction Lymphadenopathy

30. Comparison of Breast Lumps Benign Breast Disease Multiple or single Rubbery texture Mobile / slippery Regular borders Tenderness (cyclic) No retraction May increase/decrease in size rapidly Cancer Unilateral Firm texture Fixed firmly Irregular border Usually painless Usually w/retraction Grows constantly

31. Palpate: Nipples Finally palpate nipple Palpate around areola. Palpate depression under nipple. Gently press nipple between thumb index finger; Discharge .

32. Others Palpation Methods; Wedge Parallel lines Concentric lines

33. Examination of Axilla

34. palpate the axilla Support patient’s arm Palpate tail between fingers and thumb. Palpate axillary lymph nodes Supraclavicular nodes. Palpable lymph nodes less than 1 cm in diameter usually are clinically insignificant

35. Pectoral group Central and apical

36. Posterior group

37. supraclavicular infraclavicular

38. BREAST SELF EXAM GOAL: Early detection IN PREPARATION FOR TEACHING: Assess: knowledge base , motivation fears and concerns family history risk factors TEACHING: Use show and tell; use finger pads EXAM: monthly, day 5-7 of menstrual cycle; after menopause same day each month Use in conjunction with mammography & CBE

39. Breast Self Exam - Step 1 Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips. Here's what you should lookfor: Breasts that are their usual size, shape, and color. Breasts that are evenly shaped without visible distortion or swelling. If you see any of the following changes, bring them to your doctor's attention: Dimpling, puckering, or bulging of the skin. A nipple that has changed position or become inverted (pushed inward instead of sticking out). Redness, soreness, rash, or swelling

40. Breast Self Exam - Step 2 and 3 Raise your arms and look for the same changes. While you're at the mirror, gently squeeze each nipple between your finger and thumb and check for nipple discharge (this could be a milky or yellow fluid or blood).

41. Breast Self Exam - Step 4 Feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few fingers of your hand, keeping the fingers flat and together. Cover the entire breast from top to bottom, side to side—from your collarbone to the top of your abdomen, and from your armpit to your cleavage

42. Breast Self Exam - Step 5 Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements described in Step 4.

43. GYNECOMASTIA

44. Mondor ’ s disease: thrombophlebitis

45. Phylloides tumor