This document provides information on clinically examining the breast. It begins with the external and internal anatomy of the breast, including lobes, lobules and ducts. It describes the arterial and venous blood supply and lymphatic drainage sites. The summary discusses taking a history regarding lumps, pain, discharge, risk factors and more. The physical exam methods are outlined, including inspection for symmetry, masses and skin/nipple changes, and palpation techniques to feel the breasts and axillary lymph nodes. Self exam instructions are provided to help with early cancer detection. Other clinical findings like gynecomastia and Mondor's disease are also mentioned.

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

8. 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

9. 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

11. 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

13. 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

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

16. 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

17. History - CA risk
factors
• Age: older
• History: family, prior dz
• Abortion
• Late menopause
• Obese
• Nulliparity
• Early menarche
AHistoryALONE

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

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

21. • 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.

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

23. • Arms pressing on
hips
• Leaning forward

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

26. skin
Skin retraction
Dimpling

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

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

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

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

31. Inspect whole skin
• Raise the breast to inspect
the undermined skin.

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

33. • 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

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

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

36. 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

37. •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.

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

39. 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

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

41. Others Palpation Methods;
-Wedge
-Parallel lines
-Concentric lines

42. Examination of Axilla

43. 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

44. Pectoral group Central and apical

45. Posterior group

46. supraclavicular infraclavicular

48. 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

49. 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

50. 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).

51. 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

53. 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.

54. GYNECOMASTIA

59. Mondor’s disease: thrombophlebitis

60. Phylloides tumor