Ppt10

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 10
The Breasts and Axillae

Anatomy and Physiology
• To describe your findings, divide the breast into
four quadrants
– Horizontal and vertical lines crossing the nipple
– Note that the axillary tail of breast tissue
extends into the anterior axillary fold
• As an alternative method, localize findings as the
time on the face of a clock and distance in
centimeters from the nipple

The Health History
• Questions about a woman’s breasts may be included in
the history or deferred to physical exam
• Questions to ask:
– Do you examine your breasts? How often?
– Do you have discomfort, pain, or lumps?
– Do you have discharge from the nipple? When does
it occur?
– During the menstrual cycle, do you examine your
breasts?
o 5-7 days after onset of menses is the ideal time

Health Promotion and Counseling
• Discuss the following with your patient
– Assessing risk of breast cancer
– Screening measures: self breast exam, clinical
breast exam, and mammography
– How to do self breast exam
– Concerns about palpable masses of the breast

Techniques of Examination
• Female breast
– Inspection
– Palpation
o Breast
o Nipple
• Male breast
• Axillae
• Special techniques

The Female Breast
• Clinical breast examination enhances detection of
breast cancers that mammography may miss and
provides opportunity for the patient to demonstrate
techniques for self-examination
• Clinicians should adopt a standardized approach
– Use a systematic and thorough search pattern
o Use finger pads
o Vary palpation pressures
o Use a circular motion

The Female Breast (cont.)
• Women and girls may feel apprehensive about the
exam
• Reassure the patient
• Use a courteous and gentle approach
• Keep the patient properly draped
• Ask the patient if she has noticed any lumps or
other problems and if she performs monthly
breast self-exam

Inspection
• Inspect the breasts with the patient in sitting position
and disrobed to the waist
• Look for skin changes (color, thickening, and unusually
prominent pores), size and symmetry, contour,
characteristics of the nipples (size, shape, direction in
which they point, rashes, ulceration, and discharge)
• Ask the patient to raise her arms above her head or
press them against the hips as this can bring out
dimpling or retraction
• Assess four views: arms at sides, arms over head, arms
pressed against hips, and leaning forward

Palpation
• Place the patient in the supine position
• Palpate a rectangular area from clavicle to inframammary
fold and midsternal line to posterior axillary line and into
axilla for the tail of the breast
• Thorough examination takes 3 minutes per breast
• Use finger pads of the 2nd, 3rd, and 4th fingers
• Use the vertical strip pattern (best validated technique)
• Palpate in small, concentric circles
– Apply light, medium, and deep pressure
• Examine the entire breast, including periphery, tail, and
axilla

Palpation (cont.)
• Lateral portion of breast
– Ask the patient to roll onto the opposite hip,
hand on forehead with shoulder pressed
against exam table
o This flattens lateral breast tissue
• Medial portion of breast
– Ask the patient to lie with shoulders flat
against the exam table; place her hand at her
neck and lift up her elbow until it is even with
her shoulder

Palpation (cont.)
• Examine breast tissue for:
– Consistency of tissues
– Tenderness
– Nodules
o Location
o Size
o Shape
o Consistency
o Delimitation
o Tenderness
o Mobility

Nipple
• Palpate each nipple
• Note elasticity

Findings Consistent with a Malignancy
• Hard consistency
• Irregular shape
• Dimpling of overlying skin
• Associated retraction of nipple
• Non-tender

Question
Which of the following characteristics of a breast
mass is LEAST suggestive of malignancy?
a. Hard consistency
b. Dimpling of overlying skin
c. Tenderness
d. Irregular shape

Answer
c. Tenderness
– Malignant masses are most likely to be non-
tender

Male Breast
• Inspect the nipple and areola for nodules,
swelling, ulceration
• Palpate the areola and breast tissue for nodules
• If the breast is enlarged:
– Distinguish between soft, fatty enlargement of
obesity and the firm disc of glandular
enlargement (gynecomastia)

Axillae
• Have patient in a sitting position
• Inspection
– Rash
– Infection
– Unusual pigmentation

Axillae (cont.)
• Palpation
– Left axilla: ask patient to relax with left arm down
– Cup together the fingers of your right hand
– Reach as high as possible toward the apex of axilla
– Fingers should lie directly behind pectoral muscles,
toward midclavicle
– Press fingers toward chest wall and slide them
downward
– Try to feel central nodes against chest wall
o One or more soft, small (<1 cm), nontender

Axillae (cont.)
• If central nodes feel large, hard, or tender—or if
there is suspicious lesion—feel for other groups of
axillary nodes
– Pectoral nodes
– Lateral nodes
– Subscapular nodes

Question
Which of the following statements about the technique
for performing a female breast exam is LEAST true?
a. Inspection of the breasts and nipples should be
performed with the patient in the sitting position and
disrobed to the waist
b. Asking the patient to raise her arms above her head
or pressing them against the hips can bring out
dimpling or retraction
c. Palpation should be performed with the patient
sitting and leaning forward
d. Palpation should include the axilla and tail of the
breast

Answer
c. Palpation should be performed with the patient
sitting and leaning forward
• Palpation should be performed with the patient
supine

Special Techniques
• Assessment of spontaneous nipple discharge
– Try to determine origin
o Compress areola with index finger
o Watch for discharge appearing through one
of the duct openings on nipple’s surface
– Note color, consistency, quantity, and exact
location

Recording Your Findings
• Initially you may want to use sentences
• As you become more familiar with terms you can
use phrases
– “Breasts symmetric and without masses. Nipples
without discharge.”
– “Breasts pendulous with diffuse fibrocystic changes.
Single firm 1 x 1 cm mass, mobile and nontender,
with overlying peau d’orange appearance in right
breast, upper outer quadrant at 11 o’clock.”
• Axillary adenopathy is usually included after neck section

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