To examine the left axilla, ask the patient to relax with the left arm down. Help by supporting the left wrist or hand with your left hand. Cup together the fingers of your right hand and reach as high as you can toward the apex of the axilla. Warn the patient that this may feel uncomfortable. Your fingers should lie directly behind the pectoral muscles, pointing toward the midclavicle. Now press your fingers in toward the chest wall and slide them downward, trying to feel the central nodes against the chest wall. Of the axillary nodes, these are the most often palpable. One or more soft, small (<1 cm), nontender nodes are frequently felt.
Enlarged axillary nodes from infection of the hand or arm, recent immunizations or skin tests in the arm, or part of a generalized lymphadenopathy. Check the epitrochlear nodes and other groups of lymph nodes.
Nodes that are large (>1 cm) and firm or hard, matted together, or fixed to the skin or to underlying tissues suggest malignant involvement.
Use your left hand to examine the right axilla.
If the central nodes feel large, hard, or tender, or if there is a suspicious lesion in the drainage areas for the axillary nodes, feel for the other groups of axillary lymph nodes:
■ Pectoral nodes—grasp the anterior axillary fold between your thumb and fingers, and with your fingers palpate inside the border of the pectoral muscle.
■ Lateral nodes—from high in the axilla, feel along the upper humerus.
■ Subscapular nodes—step behind the patient and with your fingers feel inside the muscle of the posterior axillary fold.
Also, feel for infraclavicular nodes and reexamine the supraclavicular nodes.
■ Special Techniques_
Assessment of Spontaneous Nipple Discharge. If there is a history Milky discharge unrelated to a of spontaneous nipple discharge, try to determine its origin by compressing prior pregnancy and lactation is the areola with your index finger, placed in radial positions around the nipple. called nonpuerperal galactorrhea.
Watch for discharge appearing through one of the duct openings on the nip- Leading causes are hormonal and ple's surface. Note the color, consistency, and quantity of any discharge and pharmacologic. the exact location where it appears.
A nonmilky unilateral discharge suggests local breast disease. The causative lesion is usually benign, but may be malignant, especially in elderly women. A benign intraductal papilloma is shown above in its usual subareolar location. Note the drop of blood exuding from a duct opening.
Examination of The Mastectomy Patient. The woman with a mastectomy warrants special care on examination. Inspect the mastectomy scar and axilla carefully for any masses or unusual nodularity. Note any change in color or signs of inflammation. Lymphedema may be present in the axilla and upper arm from impaired lymph drainage after surgery. Palpate gently along the scar—these tissues may be unusually sensitive. Use a circular motion with two or three fingers. Pay special attention to the upper outer quadrant and axilla. Note any enlargement of the lymph nodes or signs of inflammation or infection.
Masses, nodularity, change in color or inflammation, especially in the incision line, suggest recurrence of breast cancer.
It is especially important to carefully palpate the breast tissue and incision lines of women with breast augmentation or reconstruction.
Instructions for The Breast Self-Examination. The office or hospital visit is an important time to teach the patient how to perform the breast self-examination (BSE). A high proportion of breast masses are detected by women examining their own breasts. Although BSE has not been shown to reduce breast cancer mortality, monthly BSE is inexpensive and may promote stronger health awareness and more active self-care. For early detection of breast cancer, the BSE is most useful when coupled with regular breast examination by an experienced clinician and mammography. The BSE is best timed just after menses, when hormonal stimulation of breast tissue is low.
PATIENT INSTRUCTIONS FOR THE BREAST SELF-EXAMINATION (BSE)
1. Lie down with a pillow under your right shoulder. Place your right arm behind your head.
2. Use the finger pads of the three middle fingers on your left hand to feel for lumps in the right breast. The finger pads are the top third of each finger.
3. Press firmly enough to know how your breast feels. A firm ridge in the lower curve of each breast is normal. If you're not sure how hard to press, talk with your health care provider, or try to copy the way the doctor or nurse does it.
1. Repeat the examination of both breasts while standing, with one arm behind your head. The upright position makes it easier to check the upper outer part of the breasts (toward your armpit). This is where about half of breast cancers are found. You may want to do the upright part of the BSE while you are in the shower. Your soapy hands will make it easy to check
4. Press firmly on the breast in an up-and-down or "strip" pattern. You can also use a circular or wedge pattern, but be sure to use the same pattern every time. Check the entire breast area, and remember how your breast feels from month to month.
5. Repeat the examination on your left breast, using the finger pads of the right hand.
6. If you find any changes, see your doctor right away.
how your breasts feel as they glide over the wet skin.
2. For added safety, you might want to check your breasts by standing in front of a mirror right after your BSE each month. See if there are any changes in the way your breasts look, such as dimpling of the skin, changes in the nipple, redness, or swelling.
3. If you find any changes, see your doctor right away.
Adapted from the American Cancer Society, www.cancer.org. Accessed 9/1/01.
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