Mosby's Guide to Physical Examination, 7th Edition

CHAPTER 12. Breasts and Axillae

EQUIPMENT

image Ruler (if mass detected)

image Flashlight with transilluminator (if mass detected)

image Glass slide and cytologic fixative (for nipple discharge)

image Small pillow or folded towel

EXAMINATION

TECHNIQUE

FINDINGS

FEMALES

With patient seated and arms hanging loosely, inspect both breasts

Inspect all quadrants and tail of Spence as shown in figure. If necessary, lift breasts with fingertips to expose lower and lateral aspects.

 

image

imageSize/shape/symmetry

EXPECTED:Convex, pendulous, or conical. Frequently asymmetric in size.

imageTexture/contour

EXPECTED:Smooth and uninterrupted.

UNEXPECTED:Dimpling or peau d’orange appearance. Changes or asymmetric appearance.

imageSkin color

EXPECTED:Consistent color

UNEXPECTED:Areas of discoloration or asymmetric appearance.

imageVenous patterns

EXPECTED:Bilateral venous networks, although pronounced generally only in pregnant or obese women.

UNEXPECTED:Unilateral network.

imageMarkings

EXPECTED:Long-standing nevi. Supernumerary nipples possible (but could be a clue to other congenital abnormalities).

UNEXPECTED:Changing or tender nevi. Lesions.

Inspect areolae and nipples

imageSize/shape/symmetry

EXPECTED:Areolae round or oval, bilaterally equal or nearly equal. Nipples bilaterally equal or nearly equal in size and usually everted, although one or both sometimes inverted.

UNEXPECTED:Recent unilateral nipple inversion or retraction.

imageColor

EXPECTED:Areolae and nipples pink to brown.

UNEXPECTED:Nonhomogeneous in color.

imageTexture/contour

EXPECTED:Areolae smooth, except for Montgomery tubercles. Nipples smooth or wrinkled.

 

UNEXPECTED:Areolae with suppurative or tender Montgomery tubercles or with peau d’orange appearance. Nipples crusting, cracking, or with discharge.

With patient in the following positions, reinspect both breasts

imageArms extended over head, or flexed behind the neck

EXPECTED: All positions breasts bilaterally symmetric with even contour.

image Hands pressed on hips with shoulders rolled forward or pushed together in front

image Seated and leaning over

image Recumbent

UNEXPECTED:Dimpling, retraction, deviation, or fixation of breasts.

image

image

image

image

With patient seated and arms hanging loosely, palpate breasts

Chest wall sweep.Place the palm of your right hand at the patient’s right clavicle at the sternum. Sweep downward from the clavicle to the nipple, feeling

EXPECTED:Tissue smooth, free of lumps.

UNEXPECTED:Lumps or nodules. Reassess with additional palpation and

for superficial lumps. Repeat the sweep until you have covered the entire right chest wall. Repeat the procedure using your left hand for the left chest wall.

characterize any masses by location, size, shape, consistency, tenderness, mobility, delineation of borders, retraction. Use transillumination to assess presence of fluid in masses.

image

Bimanual digital palpation.Place one hand, palmar surface facing up, under the patient’s right breast. Position your hand so that it acts as a flat surface against which to compress the breast tissue. Walk the fingers of the other hand across the breast tissue, feeling for lumps as you compress the tissue between your fingers and your flat hand. Repeat the procedure for the other breast.

EXPECTED:Tissue generally firm, nontender, free of lumps. During menstrual cycle, cyclic pattern of breast enlargement, increased nodularity, tenderness.

UNEXPECTED:Lumps or nodules. Reassess with additional palpation and characterize any masses by location, size, shape, consistency, tenderness, mobility, delineation of borders, retraction. Use transillumination to assess presence of fluid in masses.

image

With patient seated, palpate for lymph nodes

Right axilla: Support patient’s lower right arm with your right hand while examining right axilla with your left hand. With palmar surface of fingers, reach deep into hollow, pushing firmly upward, then bring fingers down, gently rolling soft tissue against chest wall and axilla. Explore apex, medial, lateral aspects along rib cage; lateral aspects along upper surface of arm; and anterior and posterior walls of axilla. Repeat mirror image of this maneuver for left axilla.

Supraclavicular area: Hook fingers over clavicle and rotate over supraclavicular fossa while patient turns head toward same side and raises shoulder. Infraclavicular area: Palpate along the clavicle using a rotary motion with your fingers.

UNEXPECTED:Nodes, especially in supraclavicular area. Describe nodes by location, size, shape, consistency, tenderness, fixation, delineation of borders.

image

With patient supine, continue palpation of breast tissue

Have patient put one hand behind head. Place a towel under shoulder of same side, as shown in figure on p. 144. Compress breast tissue between fingers and chest wall, using rotary motion of fingers. Using finger pads, systematically palpate each breast in all four quadrants, including tail of Spence and over areolae. Push gently but firmly toward chest while rotating fingers clockwise or counterclockwise, following a vertical strip, concentric circle, or wedge pattern. At each point press inward, using three depths of palpation: light, medium, and deep.

Return to the nipple and with two fingers gently depress the tissue inward into the well behind the areola. Repeat palpation maneuvers for other breast.

EXPECTED:Tissue generally dense, firm, elastic but sometimes lobular. May be fine and granular in older women. Inframammary ridge may be felt along lower edge of breast. During menstrual cycle, cyclic pattern of breast enlargement, increased nodularity, tenderness.

UNEXPECTED:Lumps or nodules. Characterize any masses by location, size, shape, consistency, tenderness, mobility, delineation of borders, retraction. Use transillumination to assess presence of fluid in masses.

 

EXPECTED:Fingers and tissue move easily inward.

 

UNEXPECTED:Lump, mass; absence of well behind areola.

image

image

MALES

Inspect both breasts

imageSize/shape/symmetry

EXPECTED:Even with chest wall. Sometimes convex (especially in overweight men).

imageSurface characteristics

UNEXPECTED:Enlarged breasts.

Inspect areolae and nipples

imageSize/shape/symmetry

EXPECTED:Areolae round or oval, bilaterally equal or nearly equal. Nipples bilaterally equal or nearly equal in size and usually everted, although one or both sometimes inverted.

UNEXPECTED:Recent unilateral nipple inversion or retraction.

imageColor

EXPECTED:Areolae and nipples pink to brown.

UNEXPECTED:Nonhomogeneous in color.

imageTexture/contour

EXPECTED:Areolae smooth, except for Montgomery tubercles. Nipples smooth or wrinkled.

UNEXPECTED:Areolae with suppurative or tender Montgomery tubercles or with peau d’orange appearance. Nipples crusting, cracking, or with discharge.

Palpate breasts and over areolae

imagePalpate briefly, following palpation steps for females.

EXPECTED:Thin layer of fatty tissue overlying muscle. Thick layer in obese men may give appearance of breast enlargement. Firm disk of glandular tissue sometimes evident.

UNEXPECTED:Lumps or nodules,

With patient seated and arms flexed at elbows, palpate for lymph nodes

imagePalpate as described for females.

UNEXPECTED:Nodes, especially in supraclavicular area. Describe nodes by location, size, shape, consistency, tenderness, fixation, delineation of borders.

AIDS TO DIFFERENTIAL DIAGNOSIS

ABNORMALITY

DESCRIPTION

Fibrocystic changes

Subjective Data:Tender and painful breasts and/or palpable lumps that fluctuate with menses; usually worse premenstrually.

Objective Data:Round, soft to firm, tense, mobile masses with well-delineated borders; usually tender; usually bilateral; multiple or single.

Fibroadenoma

Subjective Data:Painless lumps that do not fluctuate with the menstrual cycle; may be asymptomatic with discovery on clinical breast examination or mammogram.

 

Objective Data:Round or discoid, firm, rubbery, mobile masses with well-delineated borders; usually nontender, usually bilateral, single; may be multiple; biopsy often performed to rule out carcinoma.

Malignant breast tumors

Subjective Data:Painless lump, change in size, shape or contour of breast, axilla may be tender if lymph nodes involved; may be asymptomatic with discovery on clinical breast examination or mammogram.

Objective Data:Palabable mass that is usually single, unilateral, irregular, or stellate in shape; poorly delineated borders; fixed, hard, stonelike, and nontender; breast may have dimpling, retraction, prominent vasculature; skin may have peau d’orange or thickened appearance; nipple may be inverted or deviate in position.

Intraductal papillomas and papillomatosis

Subjective Data:Spontaneous nipple discharge, usually unilateral; usually serous or bloody.

Objective Data:Single duct unilateral nipple discharge provoked on physical examination.

Gynecomastia

Subjective Data:Breast enlargment in males.

Objective Data:Smooth, firm, mobile, tender disk of breast tissue behind areola, unilaterally or bilaterally.

Mastitis

Subjective Data:Sudden onset of swelling, tenderness, redness, and heat in the breast; usually chills, fever.

Objective Data:Tender, hard breast mass, with an area of fluctuation, erythema, and heat; may have discharge of pus (suppuration).

Pediatric Variations

EXAMINATION

TECHNIQUE

FINDINGS

Palpate and compress nipples

 

EXPECTED:Breast enlargement is not unusual in newborns. “Witch’s milk” may be expressed.

Assess stage of pubertal development

In females, assess the stage of breast development.

EXPECTED:The duration and tempo of each stage and sequence are quite variable between individuals. Tanner stages of breast development are shown on p. 148.

Five stages of breast development in females. From Van Wieringen et al, 1971. Reprinted by permission of Kluwer Academic Publishers.

image

 

AIDS TO DIFFERENTIAL DIAGNOSIS

ABNORMALITY

DESCRIPTION

Premature thelarche

Subjective Data:Breast enlargement before onset of puberty

Objective Data:Degree of enlargement varies from very slight to fully developed breasts. Usually bilateral. Other signs of sexual maturation may be absent.

SAMPLE DOCUMENTATION

Subjective.A 42-year-old female noticed a “knot” in her right lower breast last week. Denies nipple discharge or skin changes. Reports normal mammogram 2 years ago. Has never had a breast lump before. Currently on last day of menses. Has breast tenderness just before menses but denies breast pain today. No family history of breast cancer.

Objective.Breasts moderate size, conical shape, left slightly larger than right. No skin lesions, contour smooth without dimpling or retraction; venous pattern symmetric. Nipple symmetric, without discharge; Montgomery tubercles bilaterally. Tissue dense, particularly in upper quadrants; 3 × 2 cm soft mass in lower left quadrant of right breast. Mobile, nontender. No nipple discharge expressed. No supraclavicular, infraclavicular, or axillary lymphadenopathy.