Examination of the Breast and lymph node

Mammary Gland

Anatomy of the breast

  • The breasts, or mammary glands, are highly specialized glands, which extend laterally from edges of the sternum to the anterior axillary fold. located between the third and seventh ribs on the anterior chest wall.
  • Each breast is divided into 15 to 20 irregularly shaped lobes separated by fibroelastic and adipose tissues.
  • The areola is a roughened, segmented, circular formation, which surround the nipple.
  • The nipple forms a small conic projection at the center of each areola and contains sensitive, erectile tissue with several openings of the milk ducts.

 

Preparation

1. Explaining the procedure to the client . Encourage her to ask questions and to tell you if discomfort is felt during the examination.

2. Privacy as possible by exposing only the anterior and lateral chest surfaces.

3. Be sure the patient is sitting comfortably with her arms resting at the sides.

Techniques

  • Inspection– palpation

 

General consideration

1.The patient must be properly gowned for this examination. All upper body clothing should be removed.

2. Breast tissue changes with age, pregnancy, and menstrual status.

3. The procedure described here can also be used for self-examination using a mirror for inspection.

 

Inspection

  • Observe the breasts for a symmetry and the direction in which the nipples point. The normal breasts may be slightly different in size and the direction in which both nipples point should be symmetrical.
  • Note the contour of the breast for dimpling which may appear as retraction of the overlying skin and may cause nipple deviation.
  • Inversion of the nipple determined to be long standing is considered normal.
  • Discharge, rash, or ulceration are considered abnormal findings.

Note changes in shape ,size, symmetry of nipple, areola and body of breast

Breast Changes in Chape and Size

 

Inverted nipples ,direction of piont

Inverted nipples

Inverted nipples

 

  • Observe the skin of the breasts for normal uniformity in color without:
  • prominent venous patterns
  • edema
  • redness
  • Edema which accentuates the sweat pores may look like an orange peel.
  • Continue inspection by asking the patient to raise her arms over her head. Observe the breasts for symmetrical movement.
  • Inspect the axilla for:
    • rashes
    • signs of infection
    • unusual pigmentation

    Orange peel

    Breast Orange peel

     

    Skin changes

    redness-infection inflammation

    Breasts redness-infection

     

    Inspection

    • Ask the patient to push down on her hips with her hands to determine less obvious changes.
    • Lesion that is fixed to the chest wall may only cause noticeable changes in the skin contour when the underlying muscles are tense.
    • Then, ask the patient to lean forward to assess the contour of the nipples.

     

    Axillary Node Examination

    Assessment of the axillary nodes is an important component of the breast exam since the lymphatics of much of the breast tissue drain toward the axilla.

    Evaluate all palpable lymph nodes for:

    • enlargement
    • hardening
    • mobility
    • tenderness

    Palpate the left axillary area

    1. Assist the patient to relax by supporting her lower arm in a slightly abducted position.

    2. Cupped the fingers of your right hand and use your fingertips to reach as high as possible towards the apex of the axilla.

    3. Feel for the central nodes which are the most easily detectable nodes.

    4. Have the patient indicate if there is any tenderness experienced as you palpate the nodes.

    5. Palpate inside the anterior axillary fold for the pectoral group of nodes located along the lower border of the pectoralis major muscle. These nodes drain most of the breast tissue.

    left axillary area

     

    Anterior Axillary Node

    Anterior Axillary Node

    Lateral Axillary Node

    Lateral Axillary Node

    Posterior Axillary Node

    Posterior Axillary Node

    6. Palpate along the lateral border of the scapula and deep into the posterior axillary fold for the subscapular group of nodes.

    7. Palpate along the upper humerus for the lateral group of nodes.

    • Repeat this procedure for the other axilla. Use your left hand to palpate the node groups and remember to support the patient’s forearm.
    • Because the lymphatics of the breasts do not completely drain into the axilla, palpate the infraclavicular and supraclavicular areas for the presence of any detectable lymph nodes.

     

    Palpation of Breast

    Palpation of the breasts is the next step of the assessment. Several different sequences can be used to perform this part of the exam. These include the:

    1. Clock

    2. Quadrant

    3. Spokes/radial sequence

     

    The American Cancer Society recommends the clock method:

    • Position the patient comfortably on her back with one hand placed under her head.
    • Beginning at the 12 o’clock position, use the pads of your fingers to move the skin in a circular motion.
    • Continue to palpate in a clockwise direction around the outer perimeter of the breast.
    • Remember to include palpation of the tissue which extends toward the axilla, or the tail of the breasts.
    • Feel for the consistency and elasticity of underlying tissue.
    • Keep in mind normal variations in breast tissue occur with aging. For example:
    • A young woman’s breast feels firm and elastic
    • The middle-aged woman’s breast feels more lobular
    • Pregnancy : Soreness , Enlarged , Visible veins, Nipples enlarged ,darker
    • In the elderly, a "stringy" or granular texture is present
  • Finally, palpate the nipple area. Continue to use a circular motion as you palpate. Use your fingers or thumb and index finger to gently compress the nipple.
  • Observe for any abnormal discharge. If present, obtain a sample for cytologic examination.
  • Alternative methods

    Breasts Palpation

     

    Whenever a mass is palpated during the examination, document the following information:

    • the location of the mass by the quadrant or clock method
    • the distance in centimeters from the nipple
    • the shape, such as round, discoid, regular, or irregular
    • consistency
    • mobility
    • tenderness

     

    REMBMER

    1. At the completion of this part of the examination, take the opportunity to remind the patient to perform a complete breast exam on a monthly basis,

    2. Preferably during the week following the menses when the breast tissue is smoother and less tender.

    3. Offer her written information that will assist in performing self-examination, and reassure the patient that her skills in palpating will improve with practice.

     

    Male Breast

    • The male breast is normally flat, and smaller than the female breast.
    • It usually contains no glandular tissue, but does have a nipple and a small areola. If the breast is slightly to moderately prominent, fat rather than glandular tissue is probably the underlying cause.
    • To perform the examination, have the patient in a sitting position with the arms relaxed at his sides when possible. Begin by inspecting the breasts. Note:
    • any discharge from the nipples
    • swelling
    • lesions
    • visible masses
  • Roll the nipple with your index finger and thumb. Then use the pads of your index and middle fingers to palpate for the consistency.
  • Move the skin in a circular motion and note any tenderness or nodules.
  • Non-inflammatory enlargement of the glandular tissue beneath the areola suggests gynecomastia.
  • Transient gynecomastia, either unilateral or bilateral, may occur with normal puberty.
  • Gynecomastia in an older males is considered abnormal.
  • Next, instruct the patient to raise both arms exposing the skin of the axilla. Carefully inspect the axilla for:
    • rashes
    • signs of infection
    • unusual pigmentation

     

    To palpate the patient’s axillary nodes:

    • Start with the left axillary area. Support the patient’s forearm with your left hand and have him relax with arm down.
    • Cup the fingers of your right hand and reach as high as you can towards the apex of the axilla, which lies between the clavicle and first rib.
    • Palpate for the central nodes which are the most detectable of the four groups of axillary nodes.
    • Bring your fingers down over the ribs and serratus muscle and try to locate the central nodes by compressing the skin against the chest wall.
    • Then palpate the pectoral or anterior nodes which are located along the lower border of the pectoralis major muscle.
    • Palpate the subscapular or posterior nodes along the lateral border of the scapula deep in the posterior axillary fold.
    • Next, palpate the lateral axillary nodes which lie along the upper humerus.
    • Repeat this procedure for the other axilla using your left hand to palpate the patient’s right axilla and compare your findings.
    • Since not all the lymph nodes draining the breast tissue are located in the axilla, also palpate the infraclavicular and supraclavicular areas for the presence of any detectable nodes.
    • Assess all palpable lymph nodes for:
    • enlargement , consistency
    • mobility ,tenderness

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