Transcript Chapter 14
Definitions, Structure and Function Chapters 14,20,21,&22 Key Definitions Gynecomastia: abnormal enlargement of one or two breasts in men. Supernumerary breast: extra breast tissue, sometimes with a nipple. Dysmenorrhea: painful menstration Dyspareunia: painful intercourse Gravida: # of pregnancies regardless of outcome. Parity: # of deliveries, regardless of outcome. Menarche: age at which menstruation begins. Key Definitions Menopause: age at which menstruation ends. Puberty: secondary sexual characteristics appear, reproductive ability develops. Androgens: male sex hormones. Circumcision: surgical removal of the prepuce (foreskin) Phimosis: abnormal tightness of the prepuce. Hypospadias: opening of the urethral meatus on ventral surface of the penis. Structure and Function Surface Anatomy Lie anterior to the pectoralis major & serratus ant. mus. Between the second and sixth ribs From lateral side of sternum to the midaxillary line. Tail of Spence: projects up and laterally into the axilla. Nipple is located below the center of the breast (milk duct openings) Areola: surrounds the nipple, contains small elevated sebaceous glands called “Montgomery’s glands/tubercles ” (secrete protective lipid material during lactation). 2.5-10 cm in diameter One breast may be slightly larger than the other, this is normal. Quadrants of Left Breast Breast may be divided into 4 quadrants UIQ LIQ LOQ UOQ extends into axilla note Tail of Spence Internal Anatomy The breast is composed of: 1. Glandular tissue 2. Fibrous tissue including suspensory ligaments (Cooper’s Ligament) provide support for breast tissue. In Cancer these become contracted and cause dimpling. 3. Adipose tissue (fat) 4. Breasts are supported by a bed of muscles: 1. 2. 3. 4. 5. Pectoralis major & minor Latissimus dorsi Serratus anterior Rectus abdominus External oblique 15-20 lobes Each with 20-40 Lobules (contain alveoli) Each empties into Lactiferous dusts to Lactiferous sinuses. (reservoir behind nipple) Milk Line Ectodermal Galactic Band Develops during 5th week of fetal devmt Most of the band atrophies except in the thoracic area Incomplete atrophy results in the development of extra nipples known as supernumerary nipples Lymphatic Drainage The breast has extensive lymphatic drainage. More than 75% drain into the ipsilateral axillary nodes. Central axillary nodes, pectoral, subscapular and lateral nodes. Internal mammary nodes ** * * Sm group flow up into infraclavicular, chest, abdomen or across to breast Developmental Considerations Diagram of breast development-note changes p 416 at puberty - breast development begins between ages 8 & 10 – stimulated by estrogen release during puberty- with the appearance of breast buds - onset of menses usually follows in 2-3 years – asymmetry in breast development is not abnormal. during pregnancy and lactation - enlarge several times normal size, colostrum after the fourth month maturity - after menopause - as estrogen secretion declines the tissue atrophies and is replaced with fatty deposits - reduction in breast size results - breasts become flabbier and hang more loosely from the chest wall as the ligaments relax Male Breast During adolescence, temporary enlargement is common (gynecomastia) Unilateral Provide reassurance Gynecomastia reappears in the aging male and may be due to testosterone deficiency. Health History Patient profile Age Gender Race Common chief complaints Breast mass, tenderness, discharge Assess characteristics Location Quality Quantity Associated manifestations Aggravating factors Alleviating factors Timing Health History Past health history Medical Breast specific vs. nonbreast specific Surgical Medications Allergies Injuries and accidents Family history Breast cancer Benign breast disease Health History Social history Alcohol use Tobacco use Work environment Home environment Economic status Ethnic background Health maintenance activities Diet Exercise Use of safety devices Health check-ups Monthly breast self-exam Mammogram Equipment Towel, drape, centimeter ruler, teaching aid for breast self-exam General approach Inspection Patient positions Subjective Data Breast Pain Lump Discharge Rash Swelling Trauma Hx of breast disease Surgery Breast self-exam, mammogram Axilla Tenderness Lump or swelling rash Assessment Inspect specific areas Breasts Axillae Areolar areas Nipples Contour (see pg 422 for illustrations) Lesions or masses Exudates Assessment Normal Findings for Inspection: Breast and axillae are flesh colored Areolar areas and nipples are darker in pigmentation Moles and nevi are normal variants No thickening or edema Minor size variation in the breasts and areolar areas Breast on dominant side usually is larger Nipples should point upward and laterally, may point outward & downward Breasts, areolar areas, nipples should be symmetrical Breasts are convex, without flattening, retractions, or dimpling Free from masses, tumors, primary or secondary lesions No discharge from nipples in nonpregnant, nonlactating female Palpation Sequential manner Supraclavicular and infraclavicular nodes Breasts with arms at side, arms raised over head Axillary lymph node region Breasts with pt in supine position Palpation while sitting Palpate Supraclavicular & Infraclavcicular lymph nodes Bimanual palpation while sitting Palpation of Axillary Nodes while sitting Palpation while supine Palpation Methods -Wedge -Concentric lines -Parallel lines Palpation of Glandular tissue Palpation of Areola Palpation of Nipple Normal Findings for Palpation Palpable lymph nodes less than 1 cm in diameter usually are clinically insignificant Palpation should not elicit pain Consistency of breast tissue is highly variable depending on age, time in menstrual cycle, and proportion of adipose tissue Breasts are usually nodular or granular before menses Variation with breast augmentation—breasts feel firm throughout Evaluation of Breast Mass Characteristics Location Definition Size Mobility Shape Tenderness Number Erythema Consistency Dimpling or retraction Lymphadenopathy P. 429 Risk Factors for Breast Cancer Age > 50 Personal history of breast cancer Mother, grandmother, or sister with breast cancer Menarche at an early age Menopause at advanced age Obesity Alcohol intake > 3 servings per day American or European descent Urban dweller (continues) Risk Factors for Breast Cancer Estrogen replacement therapy (ERT), Hormone (HRT) Nulliparous First birth after age 30 Higher education and socioeconomic status Atypical hyperplasia Significant mammographic breast density (indicates a grter amt of glandular tissue) BRCA 1 or BRCA 2 gene mutation Jarvis p.416 •Mutation of BRCA1 and BRCA2 genes •Previous positive breast biopsy or irrradiation •Menopause after 50s •White race •Long term use of HRT •No breast feeding •Physical inactivity Breast Cancer Second major cause of death from cancer in women identify risk factors 70% of breast cancers occur with only age and gender as identifiable risk. 5 year survival rate for localized breast cancer is 98%. If cancer has spread regionally, the rate is 76 to 88%. Breast Self-Exam Video in lab See handout last pages Teach during palpation stage of assessment Check for dimpling, retraction, breast flattening, discharge Also report redness, inflammation, masses, puckering, sunken areas, asymmetrical nipples direction, bleeding, lesions Benign Breast Disease •Cyclic Swelling •Pain, cyclic: non-cyclic •Nodularity, cyclic: non-cyclic bilaterally mobile, feel rubbery like water balloons •Dominant lumps •Nipple discharge •Infections/inflammations 50% have some form of benign breast Disease. Rule out cancer with biopsy Sometimes difficult to detect cancer lumps Cancer •Solitary, unilateral non-tender mass •Single focus (one area) •Solid, hard, dense and fixed to tissues or skin as cancer becomes invasive •Borders irregular and poorly delineated •Grows constantly •May have pain or be painless •Most common in upper outer quadrant 30-80 yrs Advanced cancer=firm or hard irregular axillary nodes skin dimpling, nipple retraction, elevation and discharge Diagnosed by biopsy Fibroadenoma •Solitary non-tender mass •Category of benign breast disease •Solid, firm, rubbery, and elastic •Round, oval, or lobulated •1 to 5 cm •Freely movable, slippery Most common between 15 to 30 Up to age 55 Grows quickly and constantly Diagnosed by biopsy Diagnostic Techniques Mammography X ray Ultrasonography Magnetic resonance imaging Gerontological Variations Breast tissue atrophies Decreased glandular tissue, resulting in granular feel Breasts become smaller, pendulous, and wrinkled Ductal tissue becomes more palpable; feels stringy Breast Self-Examination (BSE) Performed once a month Performed on a fixed date each month, or 8 days after menses Avoid completing during menstruation or ovulation Use calendar for monthly reminder Include significant other in examination process Breast Self-Examination (BSE) Bed (B): Supine position Use palmar surface of fingers Place right arm over head and palpate right breast Move in concentric circles from the periphery inward Squeeze the nipple to examine for discharge Use same procedure to check left breast Breast Self-Examination (BSE) Standing (S) Repeat previous process in standing position Stand before mirror, arms at side Assess for symmetry, retractions, dimpling, inverted nipples, or nipple deviation Repeat with arms above head Repeat with hands pressed into hips Lying Down & Standing BSE