Assessment of the breast
Dr. Aziz ASLANOĞLU
Chapter (12)
Assessment of the breast
Breast Anatomy
• Breast contains 15-20 lobes
• Fat covers the lobes and shapes the breast
• Lobules fill each lobe
• Sacs at the end of
lobules produce milk
• Ducts deliver milk to the nipple
Breast Clock and Quadrants
Regional Lymph Nodes for Breast
• A: Pectoralis major muscle
• B: Axillary lymph nodes level I
• C: Axillary lymph nodes level II
• D: Axillary lymph nodes level III
• E: Supraclavicular lymph nodes
• F: Internal mammary lymph nodes
Assessment 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.
• They are 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 fibro
elastic and adipose tissues. The areola is a roughened, segmented, circular
formation, which surround the nipple.
Subjective data
•
•
•
•
Tenderness, pain, swelling, or change in size of breasts.
Change in position of nipple or nipple discharge.
Presence of cysts, lumps, and lesions.
History of prior breast surgery
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Female Breast
Inspection: Best done in sitting position with arms relaxed at sides
• Carefully observe the breasts for symmetry. The normal breasts may be slightly
different in size. If necessary, reassure the patient that any difference in size is normal.
• Inspect Areola and nipples for position, pigmentation, inversion, discharge, crusting &
masses.
• Examine the breast tissue for size, shape, color, and contour
• Assess level of breasts, notes any retractions or dimpling of the skin.
• Ask client to elevate her hands over her head, repeat the observation.
• Ask client to press her hands to her hips and repeat observation.
• Inspect the axilla for: rashes, signs of infection and unusual pigmentation
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Palpation: Best done in recumbent position:
• Raise the arm of client on the side of the breast being palpated above client’s head.
• Palpate the breast from less painful or less diseased area (Use on palpation palmer
aspects of the fingers in a rotating motion, compressing the breast tissue against the
chest wall, this is done quadrant by until the entire breast has been palpated.
• Note skin texture, moisture, temperature, or masses.
• Gently squeeze the nipple and note any expressible discharge. "Normally not
present in non lactating women".
• Repeat examination on the opposite breast & compare findings.
• If mass is palpated, its location, size, shape, consistency, mobility and associated
tenderness are reported
• Remember the breast may feel slightly more fibrotic or be somewhat tender just
prior to or during the menses.
• Palpate using palmar surfaces of index, middle & ring fingers of both
hands, sweeping down clock face positions.
• N.B. Most carcinomas present in upper, outer quadrant
• Remember;
• Inframammary fold
• Axillary tail of Spence
• Nipple discharge (explain important to
check for discharge, gain permission,
gain permission)
• Nipple signs; 6 D’s
Paget’s Disease
Depression
Discharge Displacement Destruction
Deviation
Male Breast
• Examination of male breast can be brief and should never be omitted.
• Observe nipple & areola for ulceration, nodules, swelling or discharge
• Instruct the patient to raise both arms, exposing the skin of the axilla.
Carefully inspect the axilla for: rashes, signs of infection and unusual
pigmentation
• Palpate the areola for nodules or tenderness
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Triple Assessment
1. Clinical Examination
2. Imaging; Mammogram (false negative rate 10% / USS (in <40yr)
3. Tissue Sampling;
-
FNAC (cytology exam of aspirate, can have 95%
sensitivity)
- Core Biopsy
- Open Biopsy
CS Extension Breast
Ext 30
Ext 10
Ext 10
Ext 10
Ext 20
Adapted from: TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992.
CS Extension Breast
TS 031 + Ext 10
Adapted from: TNM Atlas, 3rd ed.
2nd rev., by B. Spiessl et al.
Springer Verlag 1992.
CS Extension Breast
TS 55 + Ext 20
Adapted from: TNM Atlas,
3rd ed. 2nd rev., by B.
Spiessl et al. Springer Verlag
1992.
CS Extension Breast
Chest wall includes
Ribs
Intercostal muscles
Serratus anterior muscle
Ext. 40
Does NOT include
Pectoral muscle (Ext 30)
Adapted from: TNM Atlas, 3rd ed.
2nd rev., by B. Spiessl et al.
Springer Verlag 1992.
CS Extension Breast
Satellite
skin nodule
Ext. 51
Skin
ulceration
Adapted from: TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992.
CS Extension Breast
61 Chest wall plus skin involvement < 50% of breast or NOS
(codes 40 + 51)
62 Chest wall plus skin involvement > 50% of breast
(codes 40 + 52)
code 40
Adapted from: TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et
al. Springer Verlag 1992.
code
51 or 52
Surgical Procedure of Primary Site: Breast
Image: NY-Presbyterian Hospitals
Surgical Procedure of Primary Site: Breast
Image: University of Chicago Hospitals
Image: NY-Presbyterian Hospitals
Chapter (13)
Assessment of Cardiovascular System
Anatomy of the Heart
• Right Atrium
• Right Ventricle
• Left Ventricle
• Left Atrium
• Superior and Inferior Vena Cava
• Pulmonary Artery
• Pulmonary Vein
• Aorta
TWO PUMPS
• Right side pumps blood to lungs
• Left side pumps blood to body
FOUR VALVES
• Two Atrioventricular Valve (AV)
• Tricuspid Valve (right atrioventricular valve)
• Mitral (left atrioventricular valve)
• Two Semilunar Valve (SL)
• Aortic valve (left semilunar valve)
• Pulmonary valve (right semilunar valve)
Subjective data:
1. Assessment of chief complaints:
• Chest pain: location, quality, duration & associated symptoms.
• Irregular heart beat: too fast, jump etc.
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2. Assessment of risk factors:• Ask about history of hypertension, diabetes, and rheumatic fever
• Ask about family history of heart attack, hypertension, stroke, and diabetes
• Describe your nutritional intake: high cholesterol, triglyceride level.
• Do you smoke? How much? And for how long?
• How do you view yourself? What do you do to relax?
• How many hours a day do you work? How do cope with stress.
• Exercise: what do you do for exercise? How often?
• Pain in calves, feet, buttocks or legs? What aggravates the pain (walking, sitting long periods, standing long
periods, sleep) what relieves the pain “elevating legs, rest, lying down”.
• In what type of chair does client usually sit?
• Does he/she cross legs frequently?
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Inspection:
• Assessment the client must be is in supine or sitting positing according to his health
• By inspection and palpation you may detect ventricular hypertrophy.
• Use source of light to inspect subtle movements in chest e.g.: pulsation, retraction etc.
• Apical pulse in left fifth intercostal space, if deviation in site observed may indicate
cardiac enlargement 6th intercostal space.
• Retractions may be seen around site of apical pulse, marked retraction may indicate
pericardial disease.
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Apical pulse
Palpation (supine position)
• Palpate from apex, moving to external border to base
• Detect abnormalities in site of palpation and abnormal sounds especially for thrill
“abnormal flow of blood”
• Describe in terms: locations of pulsation in relation to mid-sternal, mid-clavicular or
axillary lines.
• Palpation of apical pulse, strength differs from thin person to obese.
• Conditions such as anxiety, anemia, fever, and hyperthyroidism may increase in force
and duration of apical pulse (you feel lifting sensation under your fingers).
• Palpation of pulse at base of the heart (putting your hand at second left intercostal
spaces at sternal borders).
Percussion: “not used in cardiac assessment”
Auscultation:
• All heart sounds are generally low pitched “low frequency” and difficult for the human ear to hear.
• Auscultation can be started from base to apex or from apex to the base.
Assess:
• Rate and rhythm of the heart beat.
• Concentrates initially on sound "1", noting its intensity and variations, possible duplication and
effects of respiration.
• Sound 1 caused by the closing of the tricuspid and mitral valves.
• Systole begins with Sound "1" & extends to Sound "2"
Then listen to Sound "2" for same characteristics.
• Sound "2": results from closing of the aortic & pulmonary valves
• Diastole begins with Sound "2" and extends to next Sound "1"
• Sound "2" louder than Sound "1" at the base of heart, and is lighter than Sound "1" at the apex.
Finally listen for extra sounds and for murmurs
• Sound "3": During diastole, rapid filling and distention of ventricles occur causes
vibrations of ventricular walls" and this known as sound "3" ". Sound "3" best heard at
the apex with bell of stethoscope. Its indicate Pathological alterations in ventricular
filling in early diastole. it represents a normal finding in children
• Sound "4": occur after Sound "3" (late diastolic filling), occur from vibrations of
ventricular wall or vibrations of the valves. It’s usually associated with cardiac disease,
often that with altered ventricular compliance
• Gallop Sound: a gallop characterized by the superimposition of abnormal third and
fourth heart sounds, usually indicative of myocardial disease.
Gallop Sound
• Heart murmurs (abnormal sounds produced by vibrations within the heart
or in the walls of large vessels “during systole or diastole”.
• Murmurs occurrence result from valve defects, changes in the blood
vessels or an increased flow of blood through a normal structure (eg, with
fever, pregnancy, hyperthyroidism).
Special maneuvers for vascular assessment
• Check for deep phlebitis by quickly squeezing calf muscles against tibia
(normally no pain)
• Check Homan's sign by extending leg and dorsi-flexing foot (normally no
pain).
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Homan's sign
Arterial and venous insufficiency of lower extremities
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