BREAST, CLINICAL

1. BREAST, CLINICAL BY PROF. MOHAMED A. EL GHARBAWI Web Site:www.dr-elgharbawi.com E-mail:elgharma2@yahoo.com

2. EMBRYOLOGY, MILK LINE

3. CROSS SECTION OF THE BREAST 1. CHEST WALL 2. PECTORALIS MUSCLE 3. LOBULES 4. NIPPLE 5. AREOLA 6. MILK DUCT 7. BREAST FAT 8. SKIN

4. SURFACE ANATOMY OF BREAST

5. LYMPH NODES

6. LYMPH DRAINAGE OF BREAST

7. STAND ON RT SIDE OF PATIENT

8. CASE SENARIOHISTORY • Personal history :حميده محمد السيد40 years old femaleManual worker at Alnassagoon Al sharkeoon in Al AASHERLiving in BelbeesNo special habitsMarried with 4 living children • Main complaint:Lemon sized lump in left breast accidentally discovered before8 months • History of present illnessOnset: the lump was accidentally discovered during bathDuration: about 8 months agoCourse: lump gradually increasing in sizeThe lump became painful since 2 months

9. CASE SENARIOHISTORY • History of present illness (Cont.):No history of nipple dischargeNo change in the nipple appearanceNo sense of tension or pain during mensesNo weight lossNo history of bone pains, cough or expectorationNot on treatment for hypertension or diabetes

10. CASE SNARIOHISTORY • Past history:No history of taking oral contraceptive pills orhormonal therapyNo significant past medical historyAppendectomy before 20 years • Menstrual history:Menarche at age of 14 yearsRegular menstruationLast menstrual period before 15 days

11. CASE SNARIOHISTORY • Marital history:Married at age of 17 years5 pregnancies (4 vaginal deliveries + 1 abortion)First delivery at age of 18 years4 children2 girls (22 & 16 years)2 boys 20 & 8All are breast fed • Family history:2 brothers & 4 sistersNo history of breast cancer or other malignancies in the mother, grandma or sisters

12. CASE SNARIOGENERAL EXAMINATION • General look & Vital signs:162 cm long & 90 Kg (obese)ladyNo pallor No yellowish coloration of scleraNo cyanosisNo Clubbing of fingersNo generalized lymphadenopathyPulse: 88 per minuteBlood pressure: 145/ 90Temp. (oral): 37.3 C

13. CASE SNARIOGENERAL EXAMINATION • Other systems:Respiratory system: No signs of lung consolidation orpleural effusionAbdomen: No palpable liver, no other palpable abdominalmasses, no evidence of ascites.Skeletal system: No bone tenderness especially over the skull orspine Cardiovascular system: NAD • P/V & P/R: NAD

14. CASE SNARIOLOCAL EXAMINATION • INSPECTION:A. Sitting position & arms resting at sidesNormal similar contour of both breasts Both breasts are equal in size Both breasts are small and pendulous Both nipples are at the same levels No nipple retraction No apparent nipple discharge Slight elevation looking like a swelling in the upper outer quadrant of left breast Skin of breasts is looking normal with no signs of inflammation or ulceration No peau d’orange , no tethering or bickering No scars , no dilated veins

15. CASE SNARIOLOCAL EXAMINATION • INSPECTION:B. Sitting position & arms are raised above the head: No tethering or bickering of skin in both breasts

16. EXAM. SITTING& LYING,CLOCKWISE

17. CASE SNARIOLOCAL EXAMINATION • PALPATION:A. Left breast (Site of main complaint):Superficial palpation:(To gain the confidence of the patient ) To check the skin temperature To test for tenderness Not warm Not tenderDeep palpation: (Verify what has been found by inspection)A single (Number) lemon (Shape)sized mass 2 by 2 cm (Size) is felt by bothtips of fingers & flat of hand at the upper outer quadrant (Site) ofleft breast

18. PALPATION SITTING& LYING Hands on

19. PALPATION OF BREAST & AXILLA

20. CASE SNARIOLOCAL EXAMINATION • PALPATION:A. Left breast (Site of main complaint):Edge: Ill defined (merge into the tissues)Consistency: Firm to hardMobility: Limited mobility, attached to surrounding breast tissue Attachments: Not attached to the skin over (You can pinch the skin over the mass) Not attached to the underlying pectoralis muscles or chest wall (when patient forward the mass moves forward + When the patient pushes her hands against her waist to contract the pectoralis muscle, the mass is not fixed)Pressure on the areola & nipple: No dischargePalpation while the patient is lying down: No nodularity

21. CASE SNARIOLOCAL EXAMINATION • PALPATION:B. Left Axilla: Two mobile, firm and non tender lymph nodes are palpable on the medial wall of the axilla. One cm each in sizeC. No palpable supraclavicular lymph nodesD. Right Breast & Axilla: NAD

22. NIPPLE & AREOLA

23. CASE SENARIOPROVISIONAL DIAGNOSIS CARCINOMA OF LEFT BREAST, STAGE II T1 (Tumor size = 2 cm ) N1 (Ipsilateral mobile axillary lymph nodes) M0 ( No distant metastases)

24. NIPPLE RETRACTION WITH BREAST CANCER

25. PALPATION

26. PALPATION OF ANTERIOR WALL OF AXILLA

27. PALPATION OF MEDIAL WALL OF AXILLA

28. Nipple Cracking

29. ACUTE MASTITIS CELLULITIS STAGE

30. BREAST ABCESS (LOCALIZED)

31. PEAU D’ORANGE

32. BREAST CANCER SKIN SIGNSPEAU D’ORANGE

33. ADVANCED BREAST CANCER

34. INFLAMMATORY BREAST CANCER

35. MAMMOGRAPH, BREAST CANCER

36. BREAST CANCER MAMMOGRAPHY

37. CASE SENARIOINVESTIGATIONS • Confirmation of diagnosis: 1. Mammography 2. FNAC 3. May be True cut or excisional biopsy • For staging: 1. Mammography of other breast2. Abdominal US3. CXR4. X-ray to the bones where there is pain5. Bone Scan • Pre operative General evaluation: 1. CBC 2. Blood urea, creatinine & electrolytes 3. Liver function tests 4. ECG

38. CASE SENARIOTREATMENT • Surgery:Modified Radical Mastectomy • Histopathology & Test for Hormone receptors • Hormonal therapyRadiotherapyChemotherapyAccording to the results of pathology • Follow-up

39. SELF EXAMINATION OF LT BREAST

40. SELF EXAMINATION OF RT BREAST