PA Boobies
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| focuses in adults- breast exam | o identification of masses, skin or vascular changes that could indicate malignancy
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| - focuses in children | o important for Tanner staging and as part of evaluation with hormonal concerns
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| Breasts: | paired mammary glands on anterior chest wall, superficial to the pectoralis major and serratus anterior muscles
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| - nipple | located centrally on the breast and surrounded by the pigmented areola, lactiferous ducts empty onto nipple. Infiltrated with smooth muscle fibers- contraction induced by tactile/sensory/ autonomic stimuli= erection of the nipple/lactiferous ducts empty
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| montgomery tubercles | sebaceous glands on areola
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| glandular tissue- lobes | 15-20 lobes per breast radiate about nipple (composed of lobules)
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| glandular tissue - lobules | 20-40 lobules per lobe. Consist of milk producing acini cells
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| acini cells | produce milk in lobules
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| lactiferous ducts | drain milk from each lobe onto nipple surface
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| fubrous breats tissue | subcutaneous, provides breast support, suspensory ligaments (cooper ligaments)
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| cooper ligaments | extend from the connective tissue layer through the breast and attach to underlying muscle fascia, providing support to breast
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| - Muscles forming floor of breast: | o Pectoralis major and minor
o Serratus anterior
o Latissimus dorsi
o Subscapularis
o External oblique
o Rectus abdominus
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| - Vascular supply of breast | internal mammary artery and lateral thoracic artery
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| - subcutaneous and retromammary fat | o supplies bulk of breast
o varies with age, pregnancy, lactation, and genetics
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| - lymphatic network | o drains breast radially and deeply to underlying lymphatics
o superficial lymphatics drain skin
o deep lymphatics drain mammary lobules
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| axillary lymph nodes | midaxillary (central), anterior axillary (pectoral), posterior axillary (subscapular), lateral axillary (brachial)
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| • midaxillary (central) nodes | high up in middle of axilla
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| • anterior axillary (pectoral) nodes | along lateral edge of the pectoralis major muscle, just inside anterior axillary fold
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| • posterior axillary (subscapular) nodes | along the lateral edge of scapula, deep in the posterior axillary fold
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| • lateral axillary (brachial) nodes | along humerus, inside upper arm
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| drainage of axillary lymph nodes | from central axillary nodes, drainage flows up to the infraclavicular and supraclavicular nodes. A small amount of drainage flows directly up to infraclavicular group, deep into the chest, into the abdomen, or directly across to the opposite breast
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| five segments for examination | upper outer quadrant, upper inner quadrant, lower outer quadrant, lower inner quadrant, Tail of spence
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| thelarche | breast development, early sign of puberty in adolescent girls
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| tanner stage 1 | preadolescent; only nipple is raised above level of the breast
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| tanner stage 2 | budding stage, bud shaped elevation of areola
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| tanner stage 3 | breast and areola enlarged, no contour separation
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| tanner stage 4 | increasing fat deposits, areola forms a secondary elevation above that of breast (occurs in approx. 1/2 of girls and in some cases persists in adulthood
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| tanner stage 5 | adult stage; areola is usually part of general breast contour and is strongly pigmented, nipple projects
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| pregnant women- breasts | lactiferous ducts proliferate, alveoli increase in number and size, breast enlarge by 2-3x, colostrum produced, areolar pigmentation increases, areola become erect, vascularization increases
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| lactating women- breasts | colostrum in first few days, milk produced 2-4 days after delivery, breasts full and tense, involution period over 3 mos. after termination
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| colostrum | secreted in first few days after delivery, more protein and minerals than does mature milk, contains antibodies and other nost resistance factors
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| older women- breast | dec. in glandular tissue replaced by fat, inframammary ridge thickens, breast hang loosely (tissue changes, relaxation of suspensory ligaments), nipples smaller and flatter, skin may be dry and thin, hair decreases in axilla
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| HPI: breast discomfort | o temporal sequence
o relationship to menses
o character
o associated symptoms
o contributory factors
o medications: non Rx or hormones
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| - breast mass or lump | o temporal sequence
o symptoms
o changes in lump
o associated symptoms
o medications: nonprescription or hormones
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| - nipple discharge | o character
o associated symptoms
o associated factors
o medications: contraceptives, hormones, phenothiazines, digitalis, steroids
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| - breast enlargement in men | hyperthyroidism, testicular tumor, Kleinfleter syndrome, medications (cimetidine, omeprazole, spironolactone, finasteride, antiHTN, antipsychotics), tx for prostate CA with androgens of GnRH analogs, drugs
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| PMH | previous breast disease, known BRCA1/BRCA2 mutation, previous other related CA, surgeries, changes in breast characteristics( during menstrual cycle), menstrual cycle hx, pregnancy, lactation, menopause, use of hormones, other meds (tamoxifen, raloxifene)
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| personal and social hx | - age
- breast support with strenuous exercise
- caffeine intake; impact on breast tissue
- breast self awareness/self examination: frequency, at what time n the menstrual cycle
- alcohol
- anabolic steroids or marijuana
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| Pregnant Women | - sensations: fullness, tingling, tenderness
- colostrum and knowledge about how to care for breasts and nipples during pregnancy
- use of supportive bra
- knowledge and information about breast feeding
- plans to breast feed, experience, expectations
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| Lactating Women | cleaning procedures, nursing bra, nipple tenderness, pain, related problems, associated problems, nursing routine, breast milk- pumping device/frequency of use, cultural beliefs, food/environment agents that affect milk, meds that cross milk blood barrier
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| older adults | - skin irritation under pendulous breasts from tissue to tissue contact or from rubbing of bra
- hormone therapy during or since menopause: name and dosage of medication; duration of therapy
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| Breast Self Exam (BSE) | - every woman should be familiar with her own breasts and report any breast change to PCP
- ACS recommends women start in their 20s
- Review recommendations for early breast cancer detection and discuss the issues related to breast cancer screening
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| Inspection of breasts with patient seated and arms at sides | compare size, symmetry, contour (conical, convex, pendulous), retractions or dimpling, skin color and texture, venous patterns, lesions, supernumerary nipples
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| supernumerary nipples | extra nipple along embryonic milk line on thorax or abdomen (usually 5-6 cm below breast near midline)
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| inspection of areolae and nipples | shape, symmetry, color, smoothness, size, nipple inversion, eversion, retraction
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| 5 D's | • discharge
• depression or inversion
• discoloration
• dermatologic changes
• deviation
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| o Peau d’ orange | • Lymphatic obstruction produces edema
• Thickens the skin and exaggerates the hair follicles, giving a pigskin or orange peel look
• Suggests cancer
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| - Reinspect Breasts in varied positions | o Arms extended over head or flexed behind neck
o Hands pressed on hips with shoulder rolled forward
o Push palms together
o Seated and leaning forward from waist
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| o chest wall sweep | with palm of hand, sweep from clavicle to the nipple, covering the area from the sternum to the midaxillary line
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| o bimanual digital palpation | walk your fingers across the breast tissue, compressing it between your fingers and the palmar surface of your other hand
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| o lymph node palpation | o palpation of the axillae and infraclavicular areas
o nodes should not be palpable
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| o Vertical strip method of palpation | • Use pads of fingers
• Keep in contact with patient’s breast at all times (glide along)
• Use 3 depths of palpation: light, medium, deep
• Gently depress the nipple
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| o Document masses any found | • Location
• Size and shape
• Consistency
• Tenderness
• Mobility
• Borders
• Retraction
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| o Males | expect to feel a thin layer of fatty tissue overlying muscle
• Obese men may have a somewhat thicker fatty layer, giving the appearance of breast enlargement
• Firm disk of glandular tissue can be felt in some men
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| o Infants | • breasts of many well newborns are enlarged for brief time- result of passively transferred estrogen
• small amount of clear or milky white fluid, commonly called “witch’s milk”
• enlargement usually disappears w/in 2 wks, rarely lasts >3 months of ag
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| o adolescents | R and L breasts may not growth same rate, breast tissue pf adolescent female feels dense, firm, and elastic. Start BSE early. Transient, unilateral or bilateral subareolar masses in males (disappear)
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| gynecomastia | unusual and unexpected enlargement that is readily noticeable
• usually temporary and benign and resolves spontaneously
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| Pregnant women (inspection) | • Increase in size
• Tenderness and tingling
• Enlarged erect nipples
• Vascular spiders and striae
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| pregnant women (palpation) | • Colostrum
• Coarse nodularity of breast tissue
• Dilated subcutaneous veins
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| o Lactating Women (palpation) | • Engorgement
• Clogged milk ducts
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| Lactating women- nipples | • Irritation or blisters
• Petechiae
• Cracking
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| older adults (inspection) | • Elongation or flattening
• Hanging tissue
• Smaller nipple size
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| older adults (palpation) | • Fine, granular glandular tissue
• Thickened inframammary ridge
• Fluid filled cysts
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| - galactorrhea | lactation not associated with child bearing
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| - paget disease | surface manifestation of underlying ductal carcinoma
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| - Mastitis | inflammation and infection of breast tissue
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| - Fibrocyctic Changes | benign fluid filled cyst formation caused by ductal enlargement
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| - Fibroadenoma | benign tumors composed of stromal and epithelial elements that represent a hyperplastic or proliferative process in a single terminal ductal unit
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| o Ductal carcinoma | arises from the epithelial lining of ducts
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| o Lobular carcinoma | originates in the glandular tissue of the lobules
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| - Fat Necrosis | benign breast lump that occurs as an inflammatory response to local injury
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| - intraductal papillomas and papillomatosis | : benign tumors of the subareolar ducts produce nipple discharge
o tiny tumors 2-3 mm
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| - duct ectasia | benign condition of the subareolar ducts that produces nipple discharge
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| Abnormalities in Children | - breast enlargement in girls before onset of puberty
- cause unknown
- breasts continue to enlarge slowly throughout childhood until full development is reached during adolescence
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