NR 509 Final Exam Study Guide
Chapter 18 Breasts and Axillae
Techniques of examination
Breast exam Inspection
• Redness suggests local infection or inflammatory carcinoma.
• Thickening and prominent pores suggest breast cancer.
• Flattening of the normally convex breast suggests cancer.
• Asymmetry due to change in nipple direction suggests an underlying cancer.
• Eczematous changes with rash, scaling, or ulceration on the nipple extending to the
areola occurs in Paget disease of the breast, associated with underlying ductal or lobular
carcinoma
• A nipple pulled inward, tethered by underlying ducts signals nipple retraction from a
possible underlying cancer. The retracted nipple may be depressed, flat, broad, or
thickened.
Breast exam positions
• Arms Over Head; Hands Pressed Against Hips; Leaning Forward.
Breast dimpling or retraction in these positions suggests an underlying cancer. Cancers
with fibrous strands attached to the skin and fascia over the pectoral muscles may cause
inward dimpling of the skin during muscle contraction.
Occasionally, these signs accompany benign conditions such as posttraumatic fat
necrosis or mammary duct ectasia, but should always be further evaluated.
Leaning forward: may reveal asymmetry or retraction of the breast, areola, or nipple
that is not otherwise visible, suggesting an underlying cancer
Breast exam palpation
Supine:
• 1. at least 3 minutes for each breast.
• 2. Use pads of the 2nd, 3rd, and 4th fingers, keeping the fingers slightly flexed.
• 3. Use vertical strip pattern
• 4. Palpate in small, concentric circles applying light, medium, and deep pressure at each
examining point. Press more firmly to reach the deeper tissues of a large breast.
• 5. Examine the entire breast, including the periphery, tail, and axilla.
To examine the lateral portion of the breast:
• ask the patient to roll onto the opposite hip, placing her hand on her forehead but
keeping the shoulders pressed against the bed
the medial portion of the breast,
, • ask the patient to lie with her shoulders flat against the bed or exam-ining table,
placing her hand at her neck and lifting up her elbow until it is even with her
shoulder
Anatomy
•
Female breast/axillae assessment
Breast Self-Exam
• best timed 5 to 7 days after menses, when hormonal stimulation of breast tissue is low.
Supine:
• with pillow under one shoulder-->finger pads of the three middle fingers-->Make
overlapping, dime-sized circular motions to feel the breast tissue-->Apply three levels of
pressure in each spot-->up-and-down or "strip" pat-tern
Standing:
• 1.hands pressing firmly down on your hips, look at your breasts for any changes of size,
shape, contour, or dimpling, or redness or scaliness of the nipple or breast skin.
• 2. Examine each underarm while sitting up or standing and with your arm only slightly
raised
Axilla Exam
• Enlarged axillary nodes may result from infection of the hand or arm, recent
immunizations or skin tests, or generalized lymphadenopathy.
• Check the epitrochlear nodes medial to the elbow and other groups of lymph nodes.
• Nodes that are large (≥1 to 2 cm) and firm or hard, matted together, or fixed to the skin
or underlying tissues suggest malignancy.
• A 35-year-old G0P0 woman presents to clinic with a complaint of bilateral nipple
discharge. This discharge started several weeks ago and has occurred at irregular
intervals since that time. She does not complain of local tenderness, redness, fever, or
any other systemic symptoms aside from slightly irregular periods over the last few
months. On examination, she is able to express a small amount of discharge, which is
sent to the laboratory and found to be consistent with breast milk but without any signs
of blood or pus. Screening laboratories are also sent, which reveal a normal blood count,
metabolic panel, thyroid-stimulating hormone, and human chorionic gonadotropin
(HCG) level. Further laboratories are still pending. Which of the following is the most
likely diagnosis?
➢ Prolactinoma
, ➢ Prolactinomas are pituitary tumors that secrete prolactin, which causes the production
of breast milk and can suppress menstruation
Breast pain
• Mastalgia = Pain without mass is not a breast cancer risk factor
Medications can cause breast pain: hormonal therapy, psychotropic drugs,
spironolactone, and digoxin.
Nipple exam
• Discharge: Galactorrhea, or the discharge of milk-containing fluid unrelated to preg-
nancy or lactation, is more likely to be pathologic when it is bloody or serous, unilateral,
spontaneous, associated with a mass, and occurring in women aged ≥40 years.
• Thickening of the nipple and loss of elasticity suggest an underlying cancer.
Lymph nodes
• A 66-year-old female museum curator presents for a routine annual examination. On
examination, a notably enlarged supraclavicular lymph node is appreciated on the right
side. The lymph node is nontender and feels firm and rubbery. She denies any localized
or systemic symptoms such as breast lumps, fevers, or night sweats. She has been taking
conjugated estrogen tablets for 9 years since menopause, though she has not taken
progestin compounds since she had a hysterectomy for heavy bleeding at age 45 years.
Which of the following is true about this presentation of lymphadenopathy?
➢ Metastatic breast cancer cells may spread directly into the infraclavicular and then
supraclavicular nodes without first causing notable changes in the axillary nodes.
Breast lymphatics
Pectoral-
• anterior: located along lower border of pectoralis major inside ant. axillary fold. Drain
anterior chest wall and breast.
Subscapular-posterior:
• lateral border of scapula, palpated deep in the posterior axillary fold. Drain post chest
and portion of arm.
Lateral nodes:
• located along upper humerus: drain arm.
--some breast lymp drains into infraclavicular or internal mammary chain of lymph
within chest.
Chapter 18 Breasts and Axillae
Techniques of examination
Breast exam Inspection
• Redness suggests local infection or inflammatory carcinoma.
• Thickening and prominent pores suggest breast cancer.
• Flattening of the normally convex breast suggests cancer.
• Asymmetry due to change in nipple direction suggests an underlying cancer.
• Eczematous changes with rash, scaling, or ulceration on the nipple extending to the
areola occurs in Paget disease of the breast, associated with underlying ductal or lobular
carcinoma
• A nipple pulled inward, tethered by underlying ducts signals nipple retraction from a
possible underlying cancer. The retracted nipple may be depressed, flat, broad, or
thickened.
Breast exam positions
• Arms Over Head; Hands Pressed Against Hips; Leaning Forward.
Breast dimpling or retraction in these positions suggests an underlying cancer. Cancers
with fibrous strands attached to the skin and fascia over the pectoral muscles may cause
inward dimpling of the skin during muscle contraction.
Occasionally, these signs accompany benign conditions such as posttraumatic fat
necrosis or mammary duct ectasia, but should always be further evaluated.
Leaning forward: may reveal asymmetry or retraction of the breast, areola, or nipple
that is not otherwise visible, suggesting an underlying cancer
Breast exam palpation
Supine:
• 1. at least 3 minutes for each breast.
• 2. Use pads of the 2nd, 3rd, and 4th fingers, keeping the fingers slightly flexed.
• 3. Use vertical strip pattern
• 4. Palpate in small, concentric circles applying light, medium, and deep pressure at each
examining point. Press more firmly to reach the deeper tissues of a large breast.
• 5. Examine the entire breast, including the periphery, tail, and axilla.
To examine the lateral portion of the breast:
• ask the patient to roll onto the opposite hip, placing her hand on her forehead but
keeping the shoulders pressed against the bed
the medial portion of the breast,
, • ask the patient to lie with her shoulders flat against the bed or exam-ining table,
placing her hand at her neck and lifting up her elbow until it is even with her
shoulder
Anatomy
•
Female breast/axillae assessment
Breast Self-Exam
• best timed 5 to 7 days after menses, when hormonal stimulation of breast tissue is low.
Supine:
• with pillow under one shoulder-->finger pads of the three middle fingers-->Make
overlapping, dime-sized circular motions to feel the breast tissue-->Apply three levels of
pressure in each spot-->up-and-down or "strip" pat-tern
Standing:
• 1.hands pressing firmly down on your hips, look at your breasts for any changes of size,
shape, contour, or dimpling, or redness or scaliness of the nipple or breast skin.
• 2. Examine each underarm while sitting up or standing and with your arm only slightly
raised
Axilla Exam
• Enlarged axillary nodes may result from infection of the hand or arm, recent
immunizations or skin tests, or generalized lymphadenopathy.
• Check the epitrochlear nodes medial to the elbow and other groups of lymph nodes.
• Nodes that are large (≥1 to 2 cm) and firm or hard, matted together, or fixed to the skin
or underlying tissues suggest malignancy.
• A 35-year-old G0P0 woman presents to clinic with a complaint of bilateral nipple
discharge. This discharge started several weeks ago and has occurred at irregular
intervals since that time. She does not complain of local tenderness, redness, fever, or
any other systemic symptoms aside from slightly irregular periods over the last few
months. On examination, she is able to express a small amount of discharge, which is
sent to the laboratory and found to be consistent with breast milk but without any signs
of blood or pus. Screening laboratories are also sent, which reveal a normal blood count,
metabolic panel, thyroid-stimulating hormone, and human chorionic gonadotropin
(HCG) level. Further laboratories are still pending. Which of the following is the most
likely diagnosis?
➢ Prolactinoma
, ➢ Prolactinomas are pituitary tumors that secrete prolactin, which causes the production
of breast milk and can suppress menstruation
Breast pain
• Mastalgia = Pain without mass is not a breast cancer risk factor
Medications can cause breast pain: hormonal therapy, psychotropic drugs,
spironolactone, and digoxin.
Nipple exam
• Discharge: Galactorrhea, or the discharge of milk-containing fluid unrelated to preg-
nancy or lactation, is more likely to be pathologic when it is bloody or serous, unilateral,
spontaneous, associated with a mass, and occurring in women aged ≥40 years.
• Thickening of the nipple and loss of elasticity suggest an underlying cancer.
Lymph nodes
• A 66-year-old female museum curator presents for a routine annual examination. On
examination, a notably enlarged supraclavicular lymph node is appreciated on the right
side. The lymph node is nontender and feels firm and rubbery. She denies any localized
or systemic symptoms such as breast lumps, fevers, or night sweats. She has been taking
conjugated estrogen tablets for 9 years since menopause, though she has not taken
progestin compounds since she had a hysterectomy for heavy bleeding at age 45 years.
Which of the following is true about this presentation of lymphadenopathy?
➢ Metastatic breast cancer cells may spread directly into the infraclavicular and then
supraclavicular nodes without first causing notable changes in the axillary nodes.
Breast lymphatics
Pectoral-
• anterior: located along lower border of pectoralis major inside ant. axillary fold. Drain
anterior chest wall and breast.
Subscapular-posterior:
• lateral border of scapula, palpated deep in the posterior axillary fold. Drain post chest
and portion of arm.
Lateral nodes:
• located along upper humerus: drain arm.
--some breast lymp drains into infraclavicular or internal mammary chain of lymph
within chest.
