Assessment of Breasts and Regional Lymphatic System

Disorders During Lactation

Lactating individuals are susceptible to specific inflammatory and obstructive conditions that require prompt identification.

• Plugged Duct: This occurs when a single milk duct becomes clogged. It is not an infection, but the area may feel tender. Management involves keeping the breast as empty as possible through frequent feeding or expression.
• Mastitis: This is an inflammatory infection that often presents in a single quadrant. Symptoms include redness, swelling, heat, and hardness, often accompanied by systemic "flu-like" symptoms such as fever, chills, malaise, and headache. Treatment typically requires antibiotics, rest, and local heat.
• Breast Abscess: A more severe complication, an abscess is a localized pocket of pus that can develop from untreated mastitis. If an abscess is suspected, nursing on the affected side must be temporarily stopped; milk should be manually expressed and discarded. Treatment may involve antibiotics or surgical incision and drainage.

Clinical Assessment: History and Physical Examination

A successful assessment begins with a comprehensive subjective and objective history to establish a baseline and identify risk factors.

Subjective Health History

Clinicians should inquire about:

• Past Medical History: Previous breast surgery, trauma, or known breast disease.
• Genetic Factors: Personal or family history of breast cancer or known BRCA1/BRCA2 gene mutations.
• Current Symptoms: Pain, lumps, unusual discharge, rashes, or swelling.
• Self-Care: Frequency of Breast Self-Examination (BSE) and the date of the last mammography.

Physical Examination Techniques

The physical exam is divided into two main phases: inspection and palpation.

1. Inspection The clinician should observe the breasts for symmetry, size, and shape. Key findings to note include:

• Skin Changes: Redness, dimpling, edema (swelling), rashes, or lesions.
• Nipple Status: Whether the nipples are protruding, flat, or inverted, and noting any recent retractions.
• Anomalies: The presence of supernumerary (extra) nipples, which should be distinguished from moles.

2. Palpation Palpation should be performed using a systematic approach, often using bimanual palpation to assess the tissue. It is recommended to palpate the unaffected breast first to establish a baseline of sensation and texture.

• Lumps: When a mass is identified, evaluate its location, size, shape, consistency (soft, firm, or hard), movability, and distinctness.
• Discharge: If discharge is present, note its color, consistency, and whether it contains blood.

Exam Tip: When assessing for lumps, always check the axilla (armpit) and supraclavicular regions. Swollen or tender lymph nodes in these areas (lymphadenopathy) can be a significant indicator of underlying infection or malignancy.

Breast Cancer: Risk Factors and Red Flags

Breast cancer is a major health concern, being the most common cancer in females. Identifying risk factors and "urgent findings" is essential for early intervention.

Risk Factors

Risk factors are categorized into those that cannot be changed and those that can be managed:

Urgent Findings (Red Flags)

The presence of any of the following requires immediate medical follow-up:

• Unexplained nipple bleeding or discharge.
• Open or ulcerating non-traumatic lesions.
• A new or growing mass, especially in a patient with a history of cancer.
• A mass that is solitary, unilateral, nontender, hard, and fixed with irregular borders (commonly found in the upper outer quadrant).

Lymphatic Drainage and Systemic Context

The lymphatic system works in tandem with the vascular system to retrieve excess fluid from tissues and filter it through lymph nodes. For the breast, drainage occurs through the axillary and supraclavicular nodes. In the context of a physical exam, assessing these nodes is vital because cancer cells often travel through the lymphatic channels to these regional stations.