1. BREAST & AXILLAE
AKMAL ABBASI,M.D

2. Anatomy of Breast A ducts B lobules
C dilated section of duct to hold milk
D nipple
E fat
F pectoralis major muscle
G chest wall/rib cage

3. Mastalgia
Mastalgia—occurs with trauma, inflammation, infection and benign breast disease.
Cyclic pain is common with normal breast, OCP and benign breast disease (Fibrocystic Disease).

4. Mastalgia
Any pain or tenderness in the breast? When did you first notice it?
Is Pain related to a specific cause?
Where is the pain? Localized or all over? Is the painful spot sore to touch?
Do you feel burning or pulling sensation?
Is the pain cyclic ? Any relation to your menstruation period?
Is the pain brought by strenuous activity esp involving one arm; a change in activity, manipulation during sex,; part of underwire bra; exercise?

5. Lump
The presence of any lump should be explored, approach any recent change or new lump with suspicion.
Ever noticed a lump or thickening in the breast? Where?
When did you first notice it? Change at all since then?
Does the lump has any relation to your menstruation period?
Notice any change in the overlying skin? Redness, warmth, dimpling, swelling?

6. Discharge
Causes: Galactorrhea, Medications (OCP, phenothiazines, diuretics, digitalis, steroids, reserpine, methyldopa, calcium channel blockers)
Bloody discharge or any discharge in the presence of lump is significant.
Any discharge from the nipple? When did you first notice it? What is the color and consistency of discharge (runny/viscous), Odor?

7. Rash Causes: Paget’s disease, eczema, dermatitis.
Any rash on the breast? When did you first notice it and where did it first start?
On the nipple, areola or surrounding skin?

8. Swelling Any swelling in the breast? In one spot or all over?
Related to your menstrual period, pregnancy or breast feeding?
Any change in bra size?

9. Trauma
A lump from an injury is due to local hematoma or edema and should resolve shortly or trauma may cause a woman to find a lump that was present before.
Any trauma or injury to the breast? Did it result in any swelling or lump, or break in skin?

10. History of Breast Diseases
Breast Cancer
Fibrocystic disease
Any history of breast disease yourself?
What type? How was this diagnosed? When did this occur?
How is it being treated?
Any breast cancer in your family? Who (sister, mother, Maternal Grandmother, daughter)?
At what age this relative had breast cancer?

11. Surgery Ever had surgery on the breast?
Was this a biopsy? What were the biopsy results?
Mastectomy? Mammoplasty (augmentation or reduction)?

12. Self Care Behaviors
The monthly practice of breast self examination (BSE) and routine clinical breast exam and mammogram are complimentary screening measures.
With good BSE practice, a woman knows how her breast normally feel and can detect any change more easily.
Mammography can reveal any cancer too small to be detected by the woman or by the most experienced examiner. However Mammography doesn’t detect all palpable lumps and interval lumps may become palpable between mammograms.
Woman ages should perform monthly BSE & should have a clinical exam (CBE) every 3 years; women 40 & older should perform monthly BSE, with an annual mammogram and annual CBE conducted close to the same time.

13. Self Care Behaviors
Have you ever been taught Breast Self examination? If so, how often do you perform it? What helps you remember?
Demonstrate technique of your BSE?
Ever had mammography--screening X-ray exam of the breast? When was the last Xray?

14. Clinical Breast Examination Technique
There are 3 specific components of the clinical breast examination that have been systematically evaluated and found to influence the accuracy of the examination.
These are the amount of time spent on the examination, the search pattern utilized, and the finger technique in palpation.
Time spent on clinical breast examination is one of the best predictors of sensitivity.
Several studies have shown that spending 2 minutes on the breast examination improves sensitivity.

15. Clinical Breast Examination Technique
With the patient supine during the examination, her hands above her head, the area for examination should extend from the clavicle, medially to the midsternum, laterally to the midaxillary line, and to the inferior portion of the breast.
In addition, the examination should include the axillary tail of breast tissue and the axilla to search for palpable lymphadenopathy.
One should be aware that the breast tissue is not evenly distributed across the chest.
Rather, 50% of the breast tissue is located in the upper outer quadrant, and 20% is located under the nipple areolar complex.

17. Clinical Breast Examination Technique
Three search patterns are commonly described.
The first is the radial spoke method -- wedges of tissue are examined beginning at the periphery toward the nipple in a radial pattern.
The second is the concentric circle method -- the breast is examined in larger or smaller concentric circles. These methods share similar limitations. Often the tissue under the nipple-areolar complex is omitted, thus as much as 20% of breast tissue goes unexamined.

18. Clinical Breast Examination Technique
Second, these 2 patterns are more likely to skip areas of tissue during the examination.
A third search pattern, often called the vertical strip pattern, has been compared directly with the 2 patterns in the examination of silicone breast models and has been shown to increase sensitivity of the examination.
This pattern examines the breast tissue in overlapping vertical strips across the chest wall. The vertical strip method is probably superior for ensuring that all breast tissue is examined, because the examiner is better able to track which areas have been examined, and the entire nipple-areolar complex is included.

19. Clinical Breast Examination Technique
The third critical aspect of the clinical breast examination is the finger technique. Again, systematic studies using both patients and silicone breast models have shown that the superior technique entails the use of the pads of the 2nd, 3rd, and 4th fingers held together, making dime-sized circles.
The finger pads begin in each circle using light pressure, then repeat in the same area with medium and deep pressure before moving to the next area for examination.
Observations of students indicate that failure to apply deep pressure limits the sensitivity of the examination in detecting deeper lesions.