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386 PHYSICAL EXAMINATION
UNIT 2
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>>
PHYSICAL EXAMINATION
EXAMINATION OF THE
SINUSES
EXAMINATION OF THE
MOUTH AND THROAT
INSPECTION Swelling noted below eyes bilaterally
PALPATION AND PERCUSSION Tenderness over right maxillary sinus;
dullness to percussion noted over right
maxillary sinus
TRANSILLUMINATION OF
THE SINUSES
INSPECTION AND PALPATION BREATH Foul smell noted
LIPS Pink, moist without lesions
TONGUE Midline, pink, well papillated without
BUCCAL MUCOSA Pink, moist without lesions
GUMS Pink and moist without swelling or
TEETH 32 present, no caries; in proper alignment
PALATE Intact, rises with phonation
THROAT Mildly erythematous with 1+ tonsils
Absence of glow noted over right
maxillary sinus
No abnormalities detected
fasciculations, lesions, swelling
or bleeding
bleeding
bilaterally and no exudates; uvula midline;
gag reex positive
EVALUATION AND CLINICAL
REASONING FOR CASE STUDY
The assessment and clinical decisions you make should reect
your scope of practice. For example, advanced practice health
professionals, such as nurse practitioners and remote area nurses
with endorsement, may be able to make diagnostic decisions and
prescribe medications without referring to a medical ofcer.
Fundamentally, all health professionals collect, evaluate and
act on consumer-focused health information, which will at times
include referral to, or collaboration with, other healthcare team
members. Nurses assess consumer responses to interventions
and determine when to escalate key changes in a consumer’s
condition. The clinical reasoning cycle provides health professionals with a framework to consider all this information in a
meaningful way for planning consumer care. These phases
are stepped out below, and draw on information presented and
collected during the health history and physical examination. We
then work through the cycle components that are relevant to this
case study (cycle components are bolded).
For Lianna, the 61-year-old woman who presents to the clinic
with facial pain, the signicant data that needs to be considered
includes the following.
Collecting cues/information
Recall and Review: In the rst instance you will need to reect
on what you know about sinusitis, upper respiratory infections,
allergy responses and the role of over-the-counter medications
to manage these symptoms and the effect this can have on
infections and pain.
Chief complaint and history of present illness
> 10 days ago, developed an upper respiratory infection
> Symptoms started with nasal congestion, purulent nasal
discharge and mild facial pressure; after 5 days, developed
thick, green, purulent nasal discharge, bilateral frontal
headache (4/10 intensity), maxillary facial pain, and bilateral
maxillary toothache and a low-grade fever (37.4°C)
> Symptoms worse when she leans over
> Has been taking decongestants every 6 hours and ibuprofen
400mg at bedtime without relief for 3 days
> Has been renovating house for the past two weeks
Processing information
Interpret: These symptoms and details of history outline the scope
of the issue for this consumer and how it is affecting her wellbeing
and ability to self-manage this deviation from normal health. So far
she is taking steps to minimise the severity of her symptoms and
control her temperature and pain levels.
Medications
> Hydrochlorothiazide 25mg every AM
> Ibuprofen for headaches 200–600mg BD PRN
> Demazin cold and u tablets – paracetamol 500mg and
phenylephrine PRN for nasal congestion (5mg)
EARS, NOSE, MOUTH AND THROAT 387
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Use of safety devices
> Not taking any precautions with home remodelling
Discriminate, Relate, Infer and Predict: Both use of medications
and past allergies need to be accurate and considered as it will be
likely that Lianna will need antibiotic therapy to combat the signs
of localised infection that are evident (thick, green, purulent nasal
discharge, bilateral frontal headache [4/10 intensity], maxillary
facial pain, and bilateral maxillary toothache; she has had a
low-grade fever [37.4°C]), along with the trigger of renovating,
making it likely that this has provided a source of localised
infection. As the nose is where air is rst ltered, it is where small
particles (such as wallpaper/glue, underlying paint or dust) have
lodged. This is more likely the source of infection as no other
precautions (e.g. face mask) have been used while undertaking
this job.
Stress
> New home arrangement with daughter and grandchild
returning home after marriage breakdown, home renovation,
recent pandemic was stressful for healthcare workers
Relate: This indicates that the body is already under stress so may
be more susceptible to infection.
Patency
> Each nare is patent.
Discriminate and Infer: This indicates no physical blockage
causing pain or swelling, therefore most likely to be mucosal
in nature.
Internal inspection
> Mucosa is red and swollen with purulent nasal discharge
bilaterally; septum deviated to the left.
Interpret: Localised signs of irritation, with infected discharge
Discriminate and Infer: Of signicance here is Lianna’s changed
physiology, often making it more difcult to clear her nostrils
and airways, therefore causing pockets for mucus to sit in, and
infection to develop.
Sinuses – Inspection
> Swelling noted below eyes bilaterally.
Interpret: Localised sign of mucus build-up and lled sinuses.
Palpation and percussion
> Tenderness over right maxillary sinus; dullness to percussion
noted over right maxillary sinus.
Interpret and Discriminate: Localised pain can be a sign
of localised infection where there is swelling, discharge
and pressure.
Relate: Dullness when percussing over an area that should
be lled with air indicates that air space is lled with uid or
mucus-like substance.
Transillumination of the sinuses
> Absence of glow noted over right maxillary sinus.
Interpret and Infer: An advanced skill, this nding validates that
sinuses are lled with mucus or uid rather than air.
Mouth and throat
> Breath
• Foul smell noted.
> Throat
• Mildly erythematous with 1+ tonsils bilaterally and no
exudates; uvula midline; gag reex positive.
Interpret and Relate: Foul-smelling breath is an indicator
of infection, and throat ndings show an indication of the
body’s immune response in trying to overcome the localised
sinus infection.
Putting it all together – synthesise information
The nurse in this case would note all of these abnormalities,
and refer to the medical ofcer. As it is likely antibiotics will
be prescribed, the nurse will need to check that medication
prescribed does not have contraindications or adverse
interactions with Lianna’s antihypertensive drugs.
Actions based on assessment ndings
The nurse should also provide additional education for
interventions that do not require a doctor’s order, such as:
1 Inhaling steam will to help loosen secretions.
2 Reduce intake of phenylephrine products as these dry mucus
production; in turn, this thickens secretions, increasing
pressure in the sinuses and therefore pain and heaviness, as
well as reducing the body’s ability to expel infected mucus.
3 Continue use of ibuprofen for analgesia and comfort measure.
4 Use a face mask to reduce the number of particles that can be
inhaled when renovating.
5 Rest and sleep as much as possible until symptoms improve;
this will aid the body’s immune response.
The nal step in the process is accurate documentation. The
nurse must document ndings, referrals, interventions, advice and
education given. The consumer would continue to have ongoing
long-term management and follow-up by specialist medical staff in
collaboration with general practitioner.
Documenting the physical examination, and clinical decisions
and interventions including education may look like this in a
clinic’s electronic client information system.
CHAPTER 11
388 PHYSICAL EXAMINATION
Entry by P. Calleja RN RACH health clinic
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CLINIC ENTRY
Lianna Potter, MRN: 2189960 DOB:13/07/1961
29/09/2022, 1345hs: Nursing.
UNIT 2
PRESENTING PROBLEM: Acute
Client presents with bilateral frontal headache pain (4/10), maxillary facial pain (6/10) with bilateral maxillary toothache.
Nasal discharge – purulent green, T – 37.4C, denies chills, sweats or other pain/respiratory symptoms. Worse when bending over, symptoms appeared
10 days ago after commencing renovation on bathroom and guest room in house. Initial symptoms included nasal congestion and mild sinus pressure.
Has been self-medicating with decongestants (phenylephrine q6/24), and ibuprofen 400 mg nocte, little relief past 3 nights, poor sleep.
T- 37.4, P- 72, R- 18, BP- 135/89, SpO2- 96% RA
Wt- 74 kg
Ht- 165 cm
EXAMINATION
Ears: Intact voice whisper test, Weber-midline, no lateralisation, +ve Rhinne test. No abnormalities noted on inspection of external or internal ear.
Nose: midline, nil external abnormalities, nares patent, internal mucosa red and swollen, purulent nasal discharge
bilaterally (when blowing nose), septal deviation to the left.
Sinuses: Swelling noted bilaterally, tender on palpation over R maxillary sinus, dullness when percussed.
Transillumination- absence of glow over R maxillary sinus.
Mouth and Throat: Foul smelling breath, nil abnormalities in lips/mouth. Throat mildly erythematous, tonsils 1+ bilaterally, nil other abnormalities
on inspection.
HISTORY
Medical hx: Hypertension since age 40, recent COVID-19 in past 3/12, chickenpox as child. All vaccinations up-to-date
Surgical Hx: Hysterectomy age 54
Current medication: Hydrochlorothiazide 25 mg every morning, Ibuprofen for headaches 200–600 mg BD PRN, Demazin cold and u tablets Paracetamol
500 mg and Phenylephrine PRN for nasal congestion (5 mg)
Social & home: lives at home with husband, renovating bathroom and guest bedroom (has not been using respiratory protection devices), recent change
to family arrangements, daughter and grandchild now living back at home after marriage breakdown, stress ++ at work with recent COVID-19 Pandemic.
Alcohol 1–2 units per week, non-smoker, Hobbies- music, golf caravanning with husband.
Work: works as nurse manager at local health service in acute care setting mental health.
Education: postgraduate qualication in nursing
Sleep: impaired for last 10 days, usually sleeps well
Exercise & Diet: reduced regular exercise this week due to pain, usually does gym exercise (walking and classes) 2–3 times per week. No change in
diet-gluten free as usual.
Stress and wellbeing: feeling better workwise than during worst staff shortages, however still tired. Up to date with well women’s checks, pap smear, routine
monitoring for HTN every 4 months. Generally, uses safety precautions (seat belts etc.) just not specically during home renovation- no mask. States good
general social supports. Concerned for daughter and grandchild’s new arrangements and adjusting to having them living at home again.
TREATMENT
Seen by Dr Guardian, script for Bactrim (800/16 0mg) 1 × BD for 5/7. Advised to take with food, review product information and seek health care if any
concerns. Educated on following interventions to manage sinusitis.
1. Steam inhalation
2. Reduce intake of phenylephrine products while on antibiotics
3. Continue use of ibuprofen as per directed on label
4. Use respiratory/face mask when working on renovation projects
5. Increase rest/sleep where possible
COUR TESY OF PAUL INE CAL LEJA, RN, L ECTUR ER, SCHOO L OF NURSING , QUEENSL AND UNI VERSIT Y OF TECHN OLOGY, BRISB ANE.
FIGURE 11.52 Documenting the physical examination
EARS, NOSE, MOUTH AND THROAT 389
CHAPTER 11
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CHAPTER RESOURCES
REVIEW QUESTIONS
For answers to these questions, see Answer section at the end of
the book.
1. On examination of a 44-year-old man’s inner ear, you notice a
darkened area or hole in his left tympanic membrane. This is
likely to be:
a. A perforated ear drum
b. A fungal infection on the ear drum
c. A bacterial infection on the ear drum
d. A tumour or ear cancer
2. Acute otitis externa is a common infection among children and
adults. Which of the following describes a typical examination
nding of otitis externa?
a. Thickening and clouding of the tympanic membrane
b. Erythema and oedema of the external auditory canal
c. Bubbles and air-uid levels are visible
d. Retraction and immobility of tympanic membrane
3. Jimmy Rees is a 27-year-old man who has been a carpenter
in a kitchen factory. Risk factors for hearing loss are noise
exposure, ageing, and which of the following?
a. Leukoplakia
b. Amphetamine use
c. Excessive alcohol use
d. Recurrent ear infections
4. During examination of the nasal mucosa, you note that the
nasal mucosa is red and inamed, and the client complains
of green and yellow nasal discharge and painful sinuses/
headache. These ndings are most consistent with:
a. The common cold
b. Acute sinusitis
c. Allergies or hay fever
d. Presence of cerebrospinal uid
5. During internal inspection of the nose, you note that the nasal
mucosa is inamed and friable, and there is bleeding. These
ndings are most consistent with which of the following?
Select all that apply.
a. Presence of a foreign body
b. Nasal inhalation of cocaine
c. Allergies or hay fever
d. Bacterial sinusitis
e. Overdose of decongestant nasal spray
f. Epistaxis
6. The paranasal sinuses are air-lled cavities lined with mucous
membranes that lighten the weight of the skull and add
resonance to the quality of the voice. The sinuses that can be
assessed on physical examination include:
a. Frontal and sphenoid sinuses
b. Frontal and ethmoid sinuses
c. Maxillary and frontal sinuses
d. Maxillary and sphenoid sinuses
7. During your assessment of a 28-year-old female client who
presents after attending a concert, you note that she speaks
with a hoarse voice and the oropharynx is red. Which condition
is this most likely to be?
a. Foetor hepaticus
b. Overuse of voice
c. Peritonsillar abscess
d. Halitosis
8. During examination of your consumer’s throat, you note that
the consumer has difculty opening her mouth and has 3+
swelling of the right tonsil with exudate. These ndings are
commonly associated with:
a. Infectious mononucleosis
b. Peritonsillar abscess
c. Viral pharyngitis
d. Diphtheria
9. During your assessment of a 15-year-old female, you note
that her breath smells of acetone and has a ‘fruity’ odour.
Acetone breath is most commonly associated with the
following condition:
a. Foetor hepaticus
b. Uraemia
c. Diabetic ketoacidosis
d. Halitosis
10. During examination of your consumer’s lips, you note clusters
of vesicles on erythematous bases with serous uid. They
are painful. This nding is consistent with which of the
following conditions?
a. Herpes simplex lesions
b. Aphthous ulcers
c. Basal cell carcinoma
d. Chancre
CLINICAL SKILLS
The following Clinical Skill is relevant to this chapter and can
be found in Tollefson & Hillman, Clinical Psychomotor Skills,
8th edition:
> 27 Healthcare teaching.
390 PHYSICAL EXAMINATION
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
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FURTHER RESOURCES
> Australasian Sleep Association: http://www.sleep.org.au
UNIT 2
> Australian and New Zealand Academy of Periodontists:
http://www.perio.org.au/
> Australian Dental Association Incorporated: http://www.ada.
org.au/
> Australian Hearing: http://www.hearing.com.au/
> Australian Society of Otolaryngology – Head and neck surgery:
http://www.asohns.org.au/
> Health Direct Australia: http://www.healthdirect.gov.au/
ear-disorders
REFERENCES
Australasian Society of Clinical Immunology and Allergy (ASCIA). (2019).
Hay fever (allergic rhinitis). Retrieved on 12 December 2022 from:
https://www.allergy.org.au/patients/fast-facts/hay-feverallergic-rhinitis
Australian Institute of Health and Welfare (AIHW). (2018). Cancer in
Aboriginal & Torres Strait Islander People of Australia. Cat. no. CAN
109. Canberra, Australia: AIHW.
Australian Institute of Health and Welfare (AIHW). (2020a). 1.15 Ear Heath,
Aboriginal and Torres Strait Islander Health Performance Framework.
Retrieved on 12 December 2022 from: https://www.indigenoushpf.gov.
au/measures/1-15-ear-health
Australian Institute of Health and Welfare (AIHW). (2020b). Allergic rhinitis
(hay fever). Retrieved on 12 December 2022 from: https://www.
indigenoushpf.gov.au/measures/1-15-ear-health
Best Practice Advocacy Centre New Zealand (BPAC). (2022). Otitis media:
a common childhood illness. Retrieved on 12 December 2022 from:
https://bpac.org.nz/2022/docs/otitis-media.pdf
Better Health Vic. (2019). Hearing problems − hyperacusis. Retrieved on
12 December 2022 from: https://www.betterhealth.vic.gov.au/health/
conditionsandtreatments/hearing-problems-reduced-toleranceto-sound
Cancer Society NZ. (2018). Oral cancer. Retrieved 9 September
2018 from: https://auckland-northland.cancernz.org.nz/
cancer-information/cancer-types/head-and-neck-cancers/
oral-cancer/?divisionId=17¢reId=1
CBG Health Research. (2015). Our older people’s oral health. Key ndings
of the 2012 New Zealand older people’s oral health survey. Auckland,
New Zealand: CBG Health Research. Retrieved 27 July 2018 from:
https://www.health.govt.nz/publication/our-older-peoples-oral-healthkey-ndings-2012-new-zealand-older-peoples-oral-health-survey
De Lacy, J., Dune, T., & Macdonald, J. (2020). The social determinants of
otitis media in Aboriginal children in Australia: are we addressing the
> Hearing House: http://www.hearinghouse.co.nz
> National Foundation for the Deaf: http://www.nfd.org.nz
> New Zealand Dental Association: http://www.nzda.org.nz/pub/
> New Zealand Sleep Apnoea Association: http://www.
sleepapnoeanz.org.nz/
> New Zealand Society of Otolaryngology – Head and Neck
Surgery Incorporated: http://www.orl.org.nz/
> Overwhelming Daytime Sleep Society of Australia: http://www.
nodss.org.au/sleep_apnoeas.html
primary causes? A systematic content review. BMC Public Health, 20,
492. https://doi.org/10.1186/s12889-020-08570-3
Deutsch, A., & Jay, E. (2021). Optimising oral health in frail older
people. Australian Prescriber, 44, 153−60. https://doi.org/10.18773/
austprescr.2021.037
Eisdell Moore Centre New Zealand (EMC). (2021). Equitable ear and
hearing care for Tamariki in Aotearoa − A national cross-sector
rero. https://www.emcentre.ac.nz/2021/12/17/equitable-ear-and-
Ko¯
hearing-care-for-tamariki-in-aotearoa-a-national-cross-sector-korero/
Health Navigator New Zealand. (2021). Tinnitus. Retrieved on 12 December
2022 from: https://www.healthnavigator.org.nz/health-a-z/t/tinnitus/
Jervis-Bardy, J., Carney, A. S., Duguid, R., & Leach, A. J. (2017).
Microbiology of otitis media in Indigenous Australian children.
The Journal of Laryngology & Otology, 131(S2), S2–S11.
Mohammed, H. (2019). Oral health of older people. PhD dissertation,
University of Otago, New Zealand. Retrieved on 12 December 2022
from: https://ourarchive.otago.ac.nz/bitstream/handle/10523/9732/
MohammedHamidS2019DClinDent.pdf?sequence=3&isAllowed=y
Tinnitus Australia. (n.d.). How many people have tinnitus? Retrieved
on 12 December 2022 from: https://www.tinnitusaustralia.org.au/
supporting-you/
Veivers, D., Williams, G., Toelle, B., Waterman, A., Guo, Y., Denison, L., …
Knibbs, L. D. (2022). The indoor environment and otitis media among
Australian children: A national cross-sectional study. International
Journal of Environmental Research and Public Health, 19 (3), 1551.
doi: 10.3390/ijerph19031551
Victorian Government. (2021). Understanding hearing loss. Retrieved
on 12 December 2022 from: https://www.vic.gov.au/understandinghearing-loss
World Health Organization (WHO). (2021). Deafness and hearing
loss. Retrieved on 12 December 2022 from: https://www.who.int/
news-room/fact-sheets/detail/deafness-and-hearing-loss
CHAPTER
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-300
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12
BREASTS AND REGIONAL NODES
LEARNING OUTCOMES
By the end of this chapter you should be able to:
1 describe the anatomy and physiology of the breasts and regional lymphatics, including
age-related variations
2 obtain a health history from a consumer with a breast or regional node health-related problem
3 demonstrate assessment techniques for the evaluation of the breasts and regional lymphatics
4 differentiate common variations and abnormal changes of the breasts
5 discuss the clinical reasoning in evaluating outcomes of health assessment and physical examination,
including documentation, health education given and relevant health referrals.
391
BACKGROUND
This chapter focuses primarily on the female breast as it is a more complex structure
than the male breast. However, it is also important to undertake breast assessment
on males, non-binary and transgender people. Breasts are an external symbol of
sexuality, femininity and nurturance in women, whereas in men, they symbolise
strength, tness and masculinity. Breast disease, specically breast cancer and its
potentially devastating effects, are well known and publicly recognised, and this
attention has generated considerable research investment. Breast cancer incidence
rates have increased signicantly over time, and this can be directly attributed to
breast screening programs. Conversely, mortality from breast cancer has decreased
steadily. Long-term survival rates have a direct correlation to early detection of
breast cancer (refer to
Screening Programs in Australia and New Zealand). Nurses can have a major impact
on breast health by teaching breast awareness and encouraging healthy lifestyle
choices, as these can diminish breast cancer risks.
These are common breast health problems in Australia and New Zealand that
may be encountered when undertaking examination:
> Benign breast diseases are the most common lesions of the breast found in
women. These include (though not exclusively) broadenomas, breast abscesses
and cysts. These are found most frequently in the childbearing age, reecting a
strong association with hormones, pregnancy and lactation. Gynaecomastia is
the most common benign disease found in men.
> Carcinoma of the breast is the most common cancer found in women in
Australia and New Zealand. Age is the biggest risk factor in developing
thedisease, with over 75% of breast cancers occurring in women over 50.
Most breast cancers are diagnosed in women with no family history; however,
approximately 5–10% relate to hereditary factors (i.e. a breast cancer gene–
BRCA1 or BRCA2) (Breast Cancer Network Australia, 2022; Breast Cancer
Table 12.6 for information related to the National Breast
392 PHYSICAL EXAMINATION
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UNIT 2
Foundation New Zealand, 2022; Cancer Australia, 2022). The lifetime risk for
women to have a diagnosis of breast cancer by the age of 85 is one in seven in
Australia and one in nine in New Zealand (Breast Cancer Trials, 2022). Breast
cancer is the most commonly diagnosed cancer for First Nations women, similar
to their counterparts in the wider Australian population. Although First Nations
women are 0.9 times as likely to be diagnosed, they are also 1.2 times more
likely to die from breast cancer (National Breast Cancer Foundation, 2022), with
this higher mortality rate attributed to a combination of factors including lower
participation in screening, advanced stage at diagnosis, geographic remoteness,
and comorbidities (AIHW, 2021; Cancer Australia, 2022). The 5-year relative
survival rate for Aboriginal and Torres Strait Islander women is also lower (81%)
compared to the general population (92%) (National Breast Cancer Foundation,
2022). In New Zealand, Maˉori women are 37% more likely to be diagnosed with
breast cancer than non-Maˉori women, and have a higher mortality rate (Breast
Cancer Foundation New Zealand, 2022). The reasons for the higher incidence
and ethnic disparities in cancer survival are complex, but likely include a range
of factors related to patient demographics, tumour biology, and inequities in
access, timeliness and quality of care (Tin Tin et al., 2018). Breast cancer in men
is uncommon and accounts for less than 1% of all breast cancers (Breast Cancer
Network Australia, 2022). Around 200 men in Australia, and around 25 menin
New Zealand, are diagnosed with breast cancer each year (Cancer Australia,
2022; Breast Cancer Foundation New Zealand, 2022).
FIGURE 12.1 Risk of breast cancer before the age of 75
SOURCE: HTTPS://WWW.BREASTCANCERTRIALS.ORG.AU/BREAST-CANCER-RESOURCES/BREAST-CANCER-STATISTICS/
ANATOMY AND PHYSIOLOGY
The breasts and regional nodes are now discussed, as is the development of the
breasts during adolescence.
BREASTS AND REGIONAL NODES 393
Tail of Spence
Lower inner
quadrant
Axillary tail of Spence
Rib
Opening of
lactiferous
duct
Lactiferous
duct
Cooper's
ligament
Adipose tissue
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Breasts
The female breasts are a pair of mammary glands located on the anterior chest
wall, extending vertically from the second to the sixth rib and laterally from the
sternal border to the axilla. Anatomically, the breast may be divided into four
quadrants: the upper inner quadrant, the lower inner quadrant, the upper outer
quadrant, and the lower outer quadrant (
extends into the axilla; this is known as the
supported by a bed of muscles: pectoralis major and minor, latissimus dorsi,
Figure 12.2). The upper outer quadrant
tail of Spence. The breasts are
serratus anterior, rectus abdominus and external oblique muscles, which extend
vertically from the deep fascia (
Figure 12.3). Cooper’s ligaments, which extend
vertically from the deep fascia through the breast to the inner layer of the skin,
provide support for the breast tissue (
In the centre of each breast is the
protrusion of erectile tissue approximately 0.5 to 1.5 cm in diameter. The
Figure 12.4).
nipple, a round, hairless, pigmented
nipple becomes more erect during sexual excitement, pregnancy, lactation,
cold temperatures and certain phases of the menstrual cycle. There are 12 to
20 minute openings on the surface of the nipple. These are openings of the
lactiferous ducts through which milk and colostrum are excreted.
Upper inner
quadrant
FIGURE 12.2 Quadrants of the left breast.
Note the numbers on the breast. They
represent the hours of a clock face that can
be used to specify the location of a nding
on the circular breast. The right breast clock
notation is a mirror image of the left breast.
12
Upper outer
quadrant
3
9
Lower outer
6
quadrant
CHAPTER 12
FIGURE 12.3 Muscles supporting the breast
The milk line, or ectodermal galactic band, shown in Figure 12.5A, develops
from the axilla to the groin during the fth week of fetal development. Most of
the band atrophies except in the thoracic area, where it forms a mammary ridge.
Incomplete atrophy of the galactic band results in the development of extra
nipples or breast tissue known as
Theadditional nipples or mammary tissue develop along the milk lines and are a
normal variant in a small percentage of adult women.
Surrounding the nipple is the
in diameter. The size and pigmentation vary from woman to woman. Several sebaceous
glands (Montgomery’s tubercles) are present on the surface of the areola. These
glands lubricate the nipple, helping to keep it supple during lactation. Hair follicles
punctuate the border of the areola.
The breast is composed of glandular, connective (Cooper’s ligaments) andadipose
tissue. The glandular tissue is arranged radially in the form of 12 to 20 lobes.
Thisdisbursement is similar to a bicycle wheel; each lobe represents a spoke of
Pectoralis major
and minor
Latissimus dorsi
Serratus anterior
Rectus abdominus
supernumerary nipples, shown in Figure 12.5B.
areola, a pigmented area approximately 2.5 to 10 cm
Pectoralis major muscle
Glandular tissue
Lobes
Areola
Nipple
FIGURE 12.4 Cross section of the left breast
394 PHYSICAL EXAMINATION
B. Supernumerary nipple
Lactiferous duct
Lactiferous sinus
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UNIT 2
A. These bands develop in utero and
later atrophy.
FIGURE 12.5 Ectodermal galactic bands
the wheel and extends from a central point (the nipple) to the outermost border
Figure 12.6). Each lobe is composed of 20 to 40 lobules that contain milk-producing
(
glands called
alveoli or acini. The lobules are arranged in grapelike bunches and
Lobule
Lobe
FIGURE 12.6 Glandular tissue of the left breast
BREASTS AND REGIONAL NODES 395
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are clustered around several ducts. These ducts gradually form one main lactiferous
(excretory) duct per lobe. Each lactiferous duct widens to form a sinus that acts as
a reservoir for milk during lactation. The duct opens onto the surface of the nipple.
The lobes are lodged in tissue composed of subcutaneous and
adipose tissue
, and it is this tissue that composes the bulk of the breast.
retromammary
The function of the female breast is to produce milk for the nourishment and
protection of neonates and infants. In many cultures, breasts provide sensual
pleasure during sexual foreplay and breastfeeding. The breasts also provide some
protection to the anterior thoracic chest wall.
The male breast is composed of a well-developed areola and a small nipple
that has immature tissue underneath. Gynaecomastia, the enlargement of male
breast tissue (
Figure 12.7), may occur normally in adolescent and in elderly males.
Thecondition is normally unilateral and temporary.
Regional nodes
The lymphatic drainage (the yellow alkaline drainage composed primarily of
lymphocytes) of the breast is via a complex network of lymph vessels and nodes.
It is estimated that a majority of the lymph from the breast ows to the axillary
nodes. The axillary nodes are composed of four groups: brachial nodes (lateral),
central axillary nodes (midaxillary), pectoral nodes (anterior), and subscapular
nodes (posterior). The central axillary nodes receive lymph from the three other
nodal groups. The lymph is then channelled from the central axillary nodes to the
infraclavicular and supraclavicular nodes. The remainder of the lymph ows into
the internal mammary chain or directly to the infraclavicular chain via the Rotter’s
nodes, deep into the chest or abdominal cavity, or to the other breast. The pattern
of lymph drainage is illustrated in
Figure 12.8.
The axillary nodes are easily accessible by palpation because of their supercial
location. The internal mammary nodes are very deep in the chest wall and are
inaccessible by palpation.
Breast development
Female breast development usually begins at 8 to 10 years of age and is stimulated by
oestrogen release during puberty. Enhanced fat deposition increases the size of the
breasts, while the ductal system, lobes and lobules increase in number and in size.
Asymmetry in breast development is not abnormal. Tanner staging, or sexual maturity
ratings, describe the pattern of adolescent breast development for females (see
Table 12.1).
FIGURE 12.7 Gynaecomastia
Supraclavicular
Infraclavicular
B
Brachial
(lateral)
Central axillary
(midaxillary)
Pectoral
(anterior)
Subscapular
(posterior)
Internal
mammary
FIGURE 12.8 Regional lymphatics and
drainage patterns of the left breast
COUR TESY OF ST EVEN M. LYN CH, M.D.
CHAPTER 12
TABLE 12.1 Sexual maturity rating (SMR) for female breast development
DEVELOPMENTAL STAGE
1 Preadolescent stage (before age 8).
Nipple is small, slightly raised.
2 Early adolescent stage. Breast bud
development (after age 8). Nipple and
breast form a small mound. Areola
enlarges. Height spurt begins.
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