Chapter 17: Breasts and Axillae
A patient, 3 weeks postpartum, tells the examiner that she is currently breastfeeding but might stop because her nipples are sore. The examiner observes dry and cracked nipples. Which of the following questions would be helpful in gaining information relevant to treating the problem?
"How do you clean your breasts?"
Which statement made by a 37 year old woman would make the examiner suspect fibrocystic disease?
"I feel a lump in my breast before my period"
What are some common breast changes that occur in older adults?
-glandular tissue atrophies and is replaced by fat -breasts tend to hang more loosely from the chest wall -suspensory ligaments relax -nipples become smaller, flatter, and lose some erectile ability -skin over area becomes more dry and thin
What are some breast changes during pregnancy?
-lactiferous ducts proliferate -the alveoli increase extensively in size and number -breasts may enlarge 2 or 3 times their prepregnancy size
What provides support for the breasts?
-subcutaneous fibrous tissues -suspensory ligaments (Cooper ligaments)
How many lobes does the glandular tissue in each breast have radiating from around the nipple?
15-20 lobes
What is the average interval from appearance of the breast bud to menarche?
2 years; varies in individuals
Milk production replaced colostrum __ to ___ days after delivery in response to surging prolactin levels, declining estrogen levels, and the stimulation of sucking.
2, 4
Fat Necrosis
Benign breast lump occurs as inflammatory response to local injury; history of trauma to the breast
Malignant breast tumors
Ductal carcinoma arises from the epithelial lining of ducts; lobular carcinoma originates in the glandular tissue of the lobules; peak incidence between ages 40-75 years old; breast may having dimpling, retraction, prominent vasculature; skin may have peau d'orange or thickened appearance
True or False: The breasts commonly return back to their prelactation size. Correct if wrong.
False; rarely
Which finding on breast examination of a male patient can result from marijuana use?
Gynecomastia
Mrs. Harris a 38 year old woman is diagnosed with mastitis. What is the likely causative agent?
Staphylococcus aureus
_______ may be evident as a result of stretching as the breasts increase in size.
Striae
Which of the following represents the first sign of puberty in girls?
Thelarche
True or False: Each breast contains a lymphatic network the drains the breast radially and deeply to underlying lymphatics.
True
True or False: Nipples should be free of crusting, cracking, or discharge.
True
Nipple compression should be included as part of the breast examination for which of the following patients?
a 48 year old woman reporting two episodes of bloody discharge from the right nipple
mammogram
a common radiologic procedure used for breast examination; the sensitivity is 77% and the specificity is 95%
What are common hormonal changes during the menstrual cycle?
a cyclical pattern of breast enlargement, increased modularity, and tenderness
A 68 year old man presents with gynecomastia. Which factor is a potential cause of the problem?
a decrease in testosterone
Cooper ligaments
a layer of subcutaneous fibrous tissue that provides support for the breast
Witch's milk
a small amount of clear or milky white fluid, commonly a result of maternal estrogen is spontaneously expressed from the breast bud
______________ ______________ is essential for revealing shadows and subtle variations in skin color and texture.
adequate lighting
What should a lactating patient keep in mind about medications?
all medications-prescription and nonprescription- should be evaluated for potential side effects in the newborn
Peau d'orange appearance
appearance of this indicates edema of the breast caused by blocking lymph drainage in advance of inflammatory breast cancer; the skin appears thickened, with enlarged pores and accentuated skin markings
Tail of Spence
area where most malignancies of the breast tissue occur
Examination of the breasts includes examination of the ___________ and relative _______ _______ chains.
axillae; lymph node
Fat necrosis
benign breast lump that occurs as an inflammatory response to local injury; necrotic fat and cellular debris become fibrotic and may contract into a scar
duct ectasia
benign condition of the subareolar ducts that produces nipple discharge; occurs most commonly in menopausal women; discharge often green or brown and may be sticky
Duct Ectasia
benign condition of the subareolar ducts that produces nipple discharge; the subareolar ducts become dilated and blocked with desquamating secretory epithelium necrotic debris and chronic inflammatory cells
Fibrocystic changes
benign fluid-filled cyst formation caused by ductal enlargement; tender and painful breasts; usually bilateral; can be multiple or single cysts
Fibroadenoma
benign tumors composed of stromal and epithelial elements that represent hyperplastic or proliferative process in a single terminal ductal unit; mobile masses with well-defined borders; usually nontender, single or multiple tumors
Intraductal papillomas and papillomatosis
benign tumors of the subareolar ducts that produce nipple discharge; spontaneous nipple discharge; usually unilateral
Supernumerary nipples are more common in which ethnicity?
blacks
What is vascular supply to the breast supplied from?
branches of the internal mammary artery and the lateral thoracic artery
Thelarche
breast development
premature thelarche
breast enlargement in girls before the onset of puberty from an unknown cause
gynecomastia
breast enlargement in male breasts; when testosterone levels are low relative to estrogen, breasts grow larger and are more noticeable; amount of breast tissue varies
What are the major focuses of breast examination in adults?
breast masses, skin, or vascular changes that could indicate malignancy
If a breast mass is felt, how should it be characterized?
by its location, size, shape, consistency, tenderness, mobility, delineation of borders, and retraction
What food and environmental changes may affect breast milk?
chocolate, alcohol, and pesticides
colostrum
clear or milky-white fluid expressed from a breast before milk production; produced and accumulates in the acinus cells (alveoli); it contains more protein and minerals than does mature milk
A supernumerary nipple is found on a white newborn infant girl. Which of the following may accompany this finding?
congenital renal or cardiac anomalies
Colostrum
contains more protein and minerals than does mature milk; contains antibodies and other host resistance factors
What causes erection of the nipple and causes the lactiferous ducts to empty?
contraction of the smooth muscle, induced by tactile, sensory, or autonomic stimuli
In what ways do breasts of females and transgender men with intact breasts vary in shape and what are the names of different shapes?
convex, pendulous, conical, and often one breast is smaller than the other
What cultural sensitivity should you as a nurse question in a lactating patient?
cultural beliefs about breast-feeding
While examining the breast of a 52 year old woman, the examiner notes nipple discharge. Which of the following diagnostic tests would be appropriate?
cytologic examination of the discharge
Areola color varies from light pink to ________________ or ___________.
dark brown, black
The breast tissue of adults will feel ________, _________, and elastic. Expected variations include the lobular feel of glandular tissue and the fine, __________ feel of breast tissue in older adults.
dense, firm, granular
On completion of the exam, with two fingers, the examiner should do what to the nipple?
depress the tissue inward into the well behind the areola; fingers and tissue should move easily inward
When palpating the breast, how should one depress the nipple?
depress well behind the areola
Having a patient seated with hands pressed against the hips with shoulders rolled forward accentuates __________ in ____________ and _____________.
deviations, contour, symmetry
What does seating with arms over the head or flexed behind the neck accentuate?
dimpling
If a breast mass is felt, one should note whether it causes ____________ or ________________.
dimpling, retraction
In the axillae, the mammary tissue is in ________ contact with the _____________ lymph nodes.
direct; axillary
What changes occur to the glandular tissue in pregnancy?
displaces connective tissue; breasts become looser and softer
Which characteristic suggests that a lesion on a patient's breast is Paget disease and NOT eczema?
does not respond to steroids
What positions should a patient assume for breast examination? Select all that apply. a. arms extended over the head or flexed behind the neck b. hands pressed on hips with shoulders rolled forward c. seated and leaning forward d. in recumbent position e. all of the above
e. all of the above
What is a Peau d'orange appearance of the skin indicate?
edema of the breast caused by blocked lymph drainage in advanced or inflammatory breast cancer
what do the nipples in pregnant patients appear as?
enlarge and are more erectile
What does breast examination in children use for and what scale is used to measure it?
evaluate premature or delayed puberty; tanner staging
What are two common nipple configurations and which is more common?
everted or inverted; everted most common
Suspensory ligaments (Cooper ligaments)
extend from the connective tissue layer through the breast and attach to the underlying muscle fascia, providing breast support
What are some potential harms of breast cancer screening?
false-positive and false-negative results, additional testing and biopsies, over diagnosis, subsequent treatment, pain from testing, and adverse psychological responses
Engorged breasts feel and look like what?
feel hard, warm, and enlarged; they look shiny and painful
The _________ tissue of carcinoma can also change the axis of the ________, causing it to point in a direction different from that of the other nipple.
fibrotic, nipple
What should one palpate the breasts using?
finger pads because they are more sensitive than your fingertips
The breasts in postmenopausal females and transgender men with intact breasts may appear ___________, elongated, and ___________ more loosely from the chest wall.
flattened, elongated
Montgomery follicles
follicles that are tiny sebaceous glands and may appear in the areola
For examination purposes, the breast tissue is divided into ___________ quadrants and a tail called the upper inner, upper outer, lower outer, lower inner, and tail of Spence that is an extension of the upper outer region.
four
Sensations in the breasts that pregnant patients may feel include _____________ , ___________________, and ________________.
fullness, tingling, tenderness
What sensations might a pregnant woman feel in her breasts?
fullness, tingling, tenderness, and bilateral increase in size
What should one inspect the nipples and areolae for? Select all that apply. a. shape b. symmetry c. color d. smoothness e. size f. nipple inversion, eversion, or retraction g. all of the above
g. all of the above
What composes the female breasts?
glandular and fibrous tissue; subcutaneous and retromammary fat
occasionally, pubescent male breasts may enlarge, a condition called ______________.
gynecomastia
Select which of the following are risk factors of breast cancer. Choose all that apply. a. increased aging b. family history of breast cancer c. whites more so than blacks d. menarche before age 12 e. menopause after age 55 f. increased amount of alcohol consumed g. women rather than men h. all of the above
h. all of the above
What should you inspect female breasts for? Select all that apply a. size b. symmetry c. contour d. retractions or dimpling e. skin color and texture f. venous patterns g. lesions h. all of the above
h. all of the above
With a patients arms __________ loosely at the sides, inspect each breast for ____________, ____________, ___________, _____________ and ____________, venous patterns, and lesions.
hanging, size, symmetry, contour, skin color, texture
What does breast tissue of the adolescent female feel like?
homogenous, dense, firm, and elastic
In a patient who has had a mastectomy, examine the unaffected breast as usual. Inspect the mastectomy sites and note any muscle loss or lymphedema that may be present. If the mastectomy was performed for cancer treatment, pay particular attention to the scar. why should one pay attention to the scar?
if malignancy recurs, it may be at the scar site
How should size be recorded?
in centimeters
Where does colostrum accumulate?
in the acinar cells (alveoli)
Unilateral venous patterns can results from _____________________________.
increased blood flow to a malignancy
mastitis
inflammation and infection of the breast tissue; most infections are staphylococcal; tender, hard breast mass with erythema and heat; may have a pus discharge
A benign tumor of the subareolar duct that produces nipple discharge is:
intraductal papilloma
Galactorrhea
lactation not associated with childbearing; elevated levels of prolactin
galactorrhea
lactation not associated with childbearing; usually from elevated levels of prolactin, resulting in milk production
What drains the milk from each lobe onto the surface of the nipple?
lactiferous duct
Regardless of the method, glide your fingers from one point to the next. Avoid ________ your fingers off the breast tissue because doing so makes it easy to miss tissue.
lifting
What are the three depths one should use when palpating the breasts?
light, medium, and deep
What color nipples are more prone to damage from breast-feeding than others?
lighter-colored more so than darker colored
Nodes that are detected should be described according to ___________, size, ________, consistency, tenderness, and ____________ of borders.
location, shape, delineation
Virchow Nodes
lymph nodes considered to be sentinel nodes for signaling lymphatic invasion of carcinoma from the abdomen or thorax
Which gender breasts consists of a small nipple and areola overlying a thin layer of breast tissue?
males
Recent unilateral inversion of a previously everted nipple suggests __________________.
malignancy
A clogged duct left unattended may result in the development of _____________.
mastitis
Engorged breasts more than 48 hours after the breasts fill with milk may indicate the onset of ____________.
mastitis
Breasts of many well newborns, male and female, are enlarged for a relatively brief time as a result of passively transferred ______________ ____________. It usually disappears within ___ weeks and rarely lasts beyond _____ months of age.
maternal estrogen, 2, 3
Tanner staging
method to determine level of sexual maturity
Female breasts extend from the second or third rid to the sixth or seventh rid from the sternal margin to the _______________ line.
midaxillary
What is a lobule and how many are in each breast lobe?
milk-producing acinar cells that empty into lactiferous ducts; 20-40 per lobe
When examining a patient's breasts, what two things should an examiner keep in mind?
modesty concerns and potential need for a chaperone
How should mobility of a mass be noted?
movable or fixed and in what directions
The ________ is located centrally, surrounded by the areola.
nipple
What is no longer performed as part of routine clinical Brest examination?
nipple compression
What nipple change commonly occurs in older adults?
nipples become smaller and flatter
Do the breasts of an adolescent female always develop at the same rate?
no
Lymph nodes are not usually or usually palpable in adults?
not usually
What muscles form the floor of the breasts?
pectoralis major, pectorals minor, serratus anterior, latissimus dorsi, subcapularis, external oblique, and rectus abdominis
What is a common variation of the areola in women?
peppering of nontender, nonsuppurative Montgomery tubercles
Areola
pigmented area surrounding the nipple that should be round or oval and bilaterally symmetric or nearly so; the color ranges from pink to black
Which two groups of patients commonly have pronounced venous networks in their breasts?
pregnant and obese women
Telangiectasis may develop on the upper chest, arms, neck, and face as a result of elevated levels of circulating estrogen in which patient group?
pregnant women in the second trimester
Symptoms consistent with underlying ductal malignancy include what?
red, scaling, crusty patch on one nipple
The areola should be _________ or ___________ and ___________ symmetric.
round, oval, bilaterally
For all patients, how should breasts appear?
should appear bilaterally symmetric, with an even contour and absence of dimpling, retraction, or deviation
Having a patient seated and leaning forward from the waist, what should the breasts look like and in what patients is this helpful with?
should hang equally; helpful with large breasts because they fall away from the chest wall and hang freely
____________ observation of both breasts is necessary to detect minor differences between them.
simultaneous
Which are typical descriptors of fibroadenoma?
single, discoid, firm, nontender
While palpating the axilla, it is best to place the patient in a _________________________________________________________ position.
sitting position with the arm flexed at the elbow
In lactating patients, palpate the breasts to determine the degree of _________.
softness
Nipple compression should be performed only if the patient reports what?
spontaneous nipple discharge
In what stage of the Tanner staging model do 75% of females being menstruation?
stage 4
What positions should a patient lie in for palpation of breast tissue?
supine using light, medium, and deep pressure
Which is the correct position in which to place a patient for breast palpation?
supine with the arm over the head and a small pillow under the shoulder of the side being assessed
Paget Disease
surface manifestation of underlying ductal carcinoma; crustiness of the nipple, areola, and surrounding skin; does not respond to steroids
What should venous patterns of in a woman's breasts?
symmetric
How should one palpate the breasts?
systemically, pushing gently but firmly, toward the chest wall, as you rotate your fingers in a clockwise or counterclockwise pattern
It is essential to include the __________________________ in palpation of the breast.
tail of spence
What should an examiner note of the nipples in lactating patients?
tenderness, pain, cracking, bleeding, retraction, problems related to feeding, exposure to air
How should a breast examination on a patient who had a lumpectomy for breast cancer differ from breast examination on patient who has to had breast cancer?
the area of the scare is palpated with two fingers using a circular motion
While performing a breast examination on a 68 year old woman, the examiner would expect which of the following findings?
the breast tissue has a granular feel to it
Involution
the interval, usually about 3 months, after termination of lactation when the breasts decrease in size
Which quadrant/portion in physical examination extends into the axillae?
the tail of Spence; portion of the upper outer
What changes occur to the areolae in pregnancy?
they become more deeply pigmented, diameter increases; nipples become more prominent, darker, and more erectile; Montgomery tubercles develop
When does thelarche represent its first sign of puberty in girls?
through breast development
With a patient in supine position, what is the ideal position for examination?
to have the nipple pointing toward the ceiling; have the patient raise one arm behind the head, then place a small pillow or folded towel under that shoulder to spread the breast tissue evenly across the chest wall
Gynecomastia
unexpected enlargement of breast tissue in men
Which finding on examination of a female patient's breasts requires further investigation?
unilateral visible venous network
A normal finding in skin texture should appear smooth, and the contour should be __________________.
uninterrupted
Which quadrant does the greatest amount of glandular tissue lie in?
upper outer
What is gynecomastia associated with?
use of prescription or recreational drug use, particularly marijuana
What occurs to mammary vascularization during pregnancy?
veins engorge and become visible as a blue network beneath the surface of the skin
Adequate exposure is also essential for breast examination, requiring that the patient be disrobed to the __________.
waist
How should one perform a bimanual digital palpation?
walk your fingers across the breast tissue, compressing it between your fingers and the palmar surface of your other hand
How should one perform a chest wall sweep?
with the palm of your hand, sweep from the clavicle to the nipple, covering the area from the sternum to the midaxillary line
