1. Chapter 16
Breasts and Axillae

2. "I may not have gone where I intended to go, but I think I have ended up where I intended to be." ---Douglas Adams

3. Breasts and Axillae The breast examination is typically performed:
When the patient has a specific breast complaint
As part of an overall annual well person examination
Examination of the breasts includes:
Examination of the axillae
Relevant lymph node chains 3

4. Breasts and Axillae (Cont.)
Major focus of the examination in adults is identification of breast masses, skin, or vascular changes that could indicate malignancy.
In children, it is important for Tanner staging and as part of the evaluation with hormonal concerns. 4

5. Females Inspect with patient seated. Compare breasts
Inspect both areolae and nipples 5

6. Females (Cont.)
Reinspect breasts with the patient in the following positions:
Arms extended over head or flexed behind the neck
Hands pressed on hips with shoulder rolled forward
Seated and leaning over
Recumbent position 6

7. Females (Cont.) Perform a chest wall sweep.
Perform bimanual digital palpation.
Palpate for lymph nodes in the axilla, down the arm to the elbow, and in the supraclavicular and infraclavicular areas.
Palpate breast tissue with patient supine, using light, medium, and deep pressure.
Depress the nipple into the well behind the areola. 7

8. Males Palpate breasts and over areolae for lumps or nodules.
Palpate for lymph nodes in the axilla, down the arm to the elbow, and in the supraclavicular and infraclavicular areas. 8

9. Breasts Glandular tissue Fibrous tissue
Lactiferous ducts drain milk from each lobe onto nipple surface.
Fibrous tissue
Provides breast support
Suspensory ligaments (Cooper ligaments)
Extend from the connective tissue layer through the breast and attach to the underlying muscle fascia providing further support 9

10. Breasts (Cont.)
Five segments (for examination purposes): four quadrants and tail
Upper outer quadrant: greatest amount of glandular tissue
Upper inner quadrant
Lower inner quadrant
Lower outer quadrant
Tail of Spence 10

11. Breasts (Cont.) Lymphatic network Nipple
Deep lymphatics drain mammary lobules
Complex of axillary lymph nodes
Nipple
Sebaceous glands (Montgomery tubercles) on areola 11

12. Children and Adolescents
Breast development
Latent phase in children and preadolescence
Thelarche (breast development) early sign of puberty in adolescent girls
Tanner’s five stages of developing sexual maturity 12

13. *

14. Pregnant Women Areolae: Vascularization increases.
increases in size and number due to placental hormones
pigment increases
become more erect
Vascularization increases.
Milk is produced 2-4 days after delivery 14

15. History of Present Illness
Breast mass or lump
Breast discomfort
Nipple discharge 15

16. History of Present Illness (Cont.)
Breast enlargement in men
History of hyperthyroidism, testicular tumor, Klinefelter syndrome
Medications
Treatment for prostate cancer: androgens or GnRH analogues
Illicit and/or recreational drugs: anabolic steroids, marijuana 16

17. History (Cont.) Changes in breast characteristics
Risk factors for breast cancer
Mammogram and other breast imaging history
Family history
First day of last menstrual period
Pregnancy and lactation
Menopause
Breast self-examination (BSE) 17

18. Inspection/ Palpation
Peau-d’orange is edema on or around the nipple and is from blocked lymph nodes
Nipple and areola—The 5 D’s
Discharge
Depression or inversion
Discoloration
Dermatologic changes
Deviation 18

19. Inspection/Palpation
Inspect breasts in varied positions.
Seated with arms extended over head or flexed behind neck
Hands pressed on hips with shoulder rolled forward
Seated and leaning forward from waist
Supine with arms above head with towel under shoulder 19

20. Palpation Document masses found. Nipples Discharge Tail of Spence
Both axillae 20

21. Palpation (Cont.) Males
Expect to feel a thin layer of fatty tissue overlying muscle.
Gynecomastia
Have patient hang arms at sides 21

22. Infants
Breasts of many well newborns, male and female, are enlarged for a relatively brief time.
Result of passively transferred maternal estrogen 22

23. Adolescents Breast tissue is based on Tanner stages Gynecomastia
Unusual and unexpected 23

24. Pregnant Women Inspection Palpation Increase in size
Tenderness and tingling
Enlarged erect nipples
Vascular spiders and striae
Palpation
Colostrum
Coarse nodularity of breast tissue
Dilated subcutaneous veins
Engorgement 24

25. Abnormalities (Breasts)
Paget disease
Surface manifestation of underlying ductal cancer
Mastitis
Inflammation and infection of the breast tissue
Fibrocystic changes
Benign fluid-filled cyst formation caused by ductal enlargement
Galactorrhea
Lactation not associated with childbearing 25

26. Abnormalities (Breast Lumps)
Malignant breast tumors
Ductal cancer arises from the epithelial lining of ducts
Lobular cancer originates in the glandular tissue of the lobules
Fibroadenoma
Benign tumors composed of stromal and epithelial elements that represent a hyperplastic or proliferative process in a single terminal ductal unit 26

27. Abnormalities (Children)
Premature thelarche
Breast enlargement in girls before onset of puberty
Cause unknown
Breasts continue to enlarge slowly throughout childhood until full development reached during adolescence 27

28. Breast Self Exam