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Breast History & Examination

Sep 19, 20245 min read

E.g. Ductal carcinoma 80%, Fibroadenoma, Lymph nodes examination, supra infra calivcal lymph nodes & Axillae lymph nodes

more common in upper quadruant of the breast.

govenile hypertrophy cell - severe enlargement in 3rd - Asymmetrical, alveoli extended, visible nodules, skin is shiny and thin, dilated vein, 4th image nipple is retracted; not inverted as its not inside yet

SURG

S. AHMED KHAN

Axillary Lymph Nodes

  • Level I: Lateral to the pectoralis minor muscle
  • Level II: Posterior to the pectoralis minor muscle
  • Level III: Medial to the pectoralis minor muscle
  • Rotter’s nodes: Between the pectoralis major and the minor muscles

Changes in the Breast During Menstrual Cycle

  • Increase in size in 2nd half of the cycle
  • Slightly painful and tender during the later part of the menstrual cycle
  • Pre-existing complaints may get worse
  • Pre-existing lump may increase in size

History

Common complaints:

  • Lump (most common)
  • Pain/tenderness (Mastalgia)
  • Change in breast size
  • Change in the nipple
  • Discharge from the nipple

Presentation of Breast Diseases

Painless lumps:

  • Carcinoma
  • Fibroadenoma
  • Fat necrosis
  • Cysts

Painful lumps:

  • Fibroadenosis
  • Abscess

Breast pain:

  • Fibroadenosis (fibrocystic disease)
  • Premenstrual pain

Changes in breast size:

  • Giant fibroadenoma
  • Phylloides tumor
  • Benign hypertrophy (bilateral)

Changes in nipple:

  • Carcinoma (retraction)
  • Paget’s disease (ulceration)

Discharge from nipple:

  • Red: Duct papilloma, carcinoma
  • Yellow/Green: Fibrocystic disease, duct ectasia
  • White/Milky: Galactorrhea

History

History taking follows the standard pattern

Detailed analysis of complaints

Important areas of history: menstrual, pregnancy, lactation (Breast feeding), family, previous breast problems

History of a Lump

  • When noticed (duration)?
  • How noticed?
  • Any change in the lump since first noticed?
  • Any change in the breast/nipple?
  • Any associated symptom? Pain, discharge
  • Any relationship with the menstrual cycle?
  • Any history of trauma?

History of Pain

  • Site
  • Duration
  • Onset and severity
  • Relationship to the menstrual cycle (cyclical or non-cyclical)
  • Aggravating factors
  • Relieving factors

History of Discharge

  • Duration
  • Colour of discharge: blood (red), serum (brown, green, straw-coloured), pus, milky
  • Spontaneous or on pressure
  • Unilateral/bilateral
  • Any change in the nipple
  • Other accompanying symptoms (pain)

Past Medical/Surgical History

  • Breast problem
  • Mammogram
  • Breast biopsy
  • Exposure to radiation (face, chest) - risk factor
  • Other medical/surgical history
  • Obesity (BMI >25) - risk factor

Menstrual History

  • Age of menarche
  • Age at menopause
    • early menarche (<12 years), late menopause (>55 years) - increases risk for carcinoma
  • Last menstrual period
  • Regularity of the menstrual cycle
  • Breast changes during the menstrual cycle

History of Pregnancy

  • Age at 1st pregnancy - younger age (<18) is protective
    • >30 years - increased risk
  • Number of pregnancies - protective
  • Lactational history - protective

Medications

  • Oral contraceptives - not a known risk
  • Hormone replacement therapy - increased risk
  • Other medications

Family History

  • At least two generations
  • Breast, gynecologic (ovarian), colon, prostate, gastric, or pancreatic cancer
  • Their age at the diagnosis of these tumors

Clinical Examination

  • Explain to your patient
  • Patient’s permission
  • Privacy
  • Nurse’s presence
  • Semi-recumbent position (45°), supine, sitting
  • Expose the upper half of the patient, both breasts exposed
  • Arms by the sides

Inspection of the Breast

  • Stand in front of the patient
  • 4 quadrants
  • Symmetry & size of breasts (underlying lump)
  • Any obvious mass or lump
  • Skin changes - redness (infection, inflammatory carcinoma), edema (peau d’orange), dimpling, ulceration (carcinoma)
  • Skin dimpling in the lower inner quadrant of the left breast associated with breast cancer
  • Changes in the nipple/areola: raised level, retraction (carcinoma, duct ectasia), ulceration (Paget’s disease)
  • Discharge from the nipple - spontaneous
  • Raise arms above the head - inspect breasts & axillae and note any change
  • Inspect the supraclavicular area

Palpation of the Breast

  • Semi-recumbent position

  • Ask for any painful area

  • Normal side first

  • Palpate with the palmar surface of the fingers for the presence of a lump

  • Lump characteristics: site, size, shape, surface, mobility, temperature, tenderness, texture, edge, attachment to skin or deep tissue For these characteristics - use the pulp of your fingers\

  • Site: More carcinoma develops in the upper outer quadrant

  • Size: Variable, Large mass - giant fibroadenoma, Phylloides tumor

  • Shape: Well defined - fibroadenoma, ill-defined - carcinoma

  • Mobility: Fibroadenoma freely mobile

  • Temperature: Raised in inflammation, inflammatory carcinoma

  • Tenderness: Inflammatory – abscess

  • Texture: Hard - carcinoma, firm - fibroadenoma, fluctuant - cyst

  • Attachment: Carcinoma, sometimes inflammatory lesions

  • Skin tethering - tumor infiltration of Cooper’s ligament pulling on the skin. Skin dimples when the tumor is moved to one side or arm raised above the head.

  • Skin fixation - when the tumor is directly fixed to the skin. The skin cannot be moved/pinched separately.

  • Muscle attachment - patient’s both hands resting on hips, test lump mobility before & after muscle contraction (ask the patient to press against hips).

Palpation of the Nipple

  • Any retraction/ulceration
  • Palpate for a mass underneath the affected nipple
  • Nipple discharge - blood (red), serum (brown, green, straw-coloured), pus, milky
  • Pathological discharge: Bloody, spontaneous, unilateral
  • Discharge spontaneous or on pressure of a segment of the areola
  • Any mass associated with the discharging duct

Palpation for the Lymph Nodes

  • Axilla, supraclavicular, infraclavicular lymph nodes

  • Patient sitting upright

  • Rt. Axilla: Hold the patient’s right elbow in your right hand. Palpate the axilla with your left hand. For the apex of the axilla, press the finger pulp upward and medially.

  • Lt. axilla - reverse

  • Palpate for supraclavicular, infraclavicular lymph nodes

  • Size, number, and fixation of lymph nodes

  • Examine the arm for any swelling

General Examination

Full general examination like any other patient

Concentrate on:

  • Chest: any effusion
  • Abdomen: hepatomegaly, ascites
  • Spine: pain, tenderness, limitation of movement

Graph View

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