School of Nursing

Christopher W. Blackwell, Ph.D., ARNP-CAssistant Professor, School of NursingCollege of Health & Public AffairsUniversity of Central Florida

NGR 5003: Advanced Health Assessment & Diagnostic Reasoning

Unit Four: Dermatological, Breasts, & Axillae :

Basic assessment of the dermatological system, breasts, and axillae Advanced assessment of the dermatological system, breasts, and axillae Assessment findings of abnormal presentations in the dermatological system, breasts,

and axillae Differential diagnoses of the dermatological system, breasts, and axillae Advanced Clinical reasoning: A case study approach

ADVANCED ASSESSMENT OF SKIN, HAIR, AND NAILS

LEARNING OBJECTIVES1. Conduct a history related to skin, hair, and nails.2. Discuss examination techniques for skin, hair, and nails.3. Identify normal age and condition variations of skin, hair, and nails.4. Recognize findings that deviate from expected findings.5. Relate symptoms or clinical findings to common pathologic conditions.

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Outline for Chapter 8: Skin, Hair, and Nails

Anatomy and Physiology Skin provides an elastic, rugged, self-regenerating, protective covering for the body. The skin and its appendages are our primary physical presentation to the world. Skin structure and physiologic processes perform the following integral functions:

Protect against microbial and foreign substance invasion and minor physical trauma

Retard body fluid loss by providing a mechanical barrier Regulate body temperature through radiation, conduction, convection, and

evaporation Provide sensory perception via free nerve endings and specialized receptors Produce vitamin D from precursors in the skin Contribute to blood pressure regulation through constriction of skin blood vessels Repair surface wounds by exaggerating the normal process of cell replacement Excrete sweat, urea, and lactic acid Express emotions

Epidermis The epidermis, the outermost part of the skin, consists of two major layers:

The stratum corium provides protection. It is composed of dead squamous cells containing keratin.

The cellular stratum synthesizes keratin cells. The basement membrane, below the cellular stratum, connects the epidermis to the

dermis. Stratum lucidum is found only in thicker skin of palms and soles. The epidermis is avascular and gets nutrition from the dermis.

Dermis The dermis is vascular connective tissue. It separates the epidermis from the

cutaneous adipose tissue. Elastin, collagen, and reticulin fibers provide strength and stability. The dermis contains sensory and autonomic motor nerve fibers.

Hypodermis The hypodermis consists of connective tissue containing fatty cells. Adipose tissue

generates heat and provides insulation and caloric reserve.

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Appendages Appendages are formed from the epidermis invaginating into the dermis. Eccrine sweat glands secrete water and regulate body temperature. Apocrine glands are deeper glands that respond to emotional stimuli by secreting

odorless white fluid. Sebaceous glands secrete sebum as regulated by hormonal levels. Hair consists of epidermal cells in the dermal layers. Vellus hair is short, fine, soft,

and nonpigmented. Terminal hair is coarser, longer, thicker, and usually pigmented.

Nails are hard plates of keratin. The pink color is from vascular beds under the plate. The cuticle is stratum corium that covers the nail root. The paronychium is soft tissue surrounding nail border.

Age- and Condition-Related Variations Infants and children. The skin of young people is smoother than that of adults

and lacks terminal hair. After birth, there is variable desquamation. Vernix caseosa, a mixture of sebum and cornified epidermis, covers the infant’s body at birth. Lanugo hair is found on shoulders and back. It is shed in about 2 weeks after birth. Head hair is shed by 2 to 3 months and is replaced by more permanent hair. Eccrine sweat glands function after the first month of life. Inactive apocrine glands make the skin less oily.

Adolescents. During puberty, the apocrine glands enlarge and become active. Sebaceous glands increase sebum production, which gives an oily appearance and predisposes the individual to acne. Coarse terminal hair appears in axillae and pubic area.

Pregnant women. During pregnancy, increased blood flow results from peripheral vasodilation and increased capillaries. Sweat and sebaceous gland activity increases. Skin thickens and fat is deposited in subdermal layers. Increased pigmentation occurs from hormonal changes.

Older adults. With age, sebaceous and sweat gland activity decreases. Epidermis thins and flattens. Vascularity in dermis decreases and becomes less elastic. Cutaneous tissue decreases. Gray hair occurs from a decrease in the number of functioning melanocytes. Density and rate of hair growth decline. Nail growth slows and nails become thicker, brittle, and yellow. They also develop ridges and are prone to split.

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Review of Related History

History of Present Illness Skin. Patients with skin problems should be asked about changes in skin such as

warts, moles, or lesions, as well as temporal sequence, symptoms, and location of any skin occurrence. Associated symptoms and factors, such as high temperature, exposure to drugs, and travel history should be listed. Patient’s response to the problem and any home treatment should be noted. Patient’s perception of the cause of the condition should also be explored.

Hair. Data relevant to a hair condition include the following: changes in hair patterns, occurrence or recurrence of problem, associated symptoms and factors (e.g., itching or drug exposures), dietary habits, patient’s reaction to the problem, and factors affecting condition.

Nails. Patients with nail conditions should be asked about the following: any changes in their nails, symptoms (e.g., pain or swelling), temporal sequence of the problem, recent exposures, and things making condition better or worse.

Past Medical History Skin. Data relevant to the past medical history include previous skin problems

(e.g., skin reactions or lesions), exposure to sunlight, changes in sensory stimuli, and systemic diseases affecting skin.

Hair. Patients with hair conditions should be questioned about any previous hair problems (e.g., loss of hair), pattern changes, and systemic problems (e.g., thyroid disease).

Nails. Past medical history should include data on previous nail problems (e.g., infections) and systemic problems (e.g., cardiac conditions) that could influence nail condition.

Family History Relevant data include current or past dermatologic diseases of family members,

allergic hereditary diseases or skin disorders, and familial hair patterns.

Personal and Social History Pertinent data include skin care habits (e.g., cosmetic use and sun exposure), hair

care habits (e.g., cleansing routine, as well as the use of any coloring or permanent products), nail care habits, use of medications, exposure to environmental or occupational hazards, and any recent psychologic or physiologic stress.

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Age- and Condition-Related Variations Infants. Relevant data include feeding and diaper history, types of clothing,

products used to wash clothes, bath practices, habits of dressing the infant, and the home environment.

Children. Explore eating patterns, disease exposure, allergic disorders and reactions, previous skin injury, hair manipulation, and nail-biting habits.

Pregnant women. Pertinent data include weeks of gestation or postpartum, hygienic practices, presence of prior skin lesions, and effects of pregnancy on previous skin lesions.

Older adults. Ask older patients about changes in touch sensation, chronic itching, susceptibility to skin infections, changes or slowness in healing, history of falling, diabetes, vascular diseases, or hair loss.

See Risk Factors: Basal and Squamous Cell Carcinoma (p. 214) and Risk Factors: Melanoma (p. 215).

Examination and Findings

Summary of Examination—Skin, Hair, and NailsSkin Ensure adequate lighting. Assess skin contour, symmetry, color. View exposed and unexposed areas. Describe lesions according to characteristics, exudates, location, and distribution. Use flashlight to see color, elevation, and borders of lesions. Use a Wood’s lamp to detect the presence of fungal infection. Smell skin odors. Feel skin for moisture, temperature, texture, turgor, and mobility. Use dorsal surface of hands and fingers to palpate skin temperature. View cysts and masses.Hair Assess color, distribution, and quantity of hair. Palpate texture. Note any hair loss, inflammation, or scarring.Nails Note nail color, length, configuration, angle at the base, and symmetry. Observe nail folds for signs of infection, warts, cysts, or tumors. Squeeze nail to test adherence.

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Summary of Skin, Hair, and Nail Findings

Life CycleVariations

Normal Findings

Typical Variations

Findings Associated with Disorders

Adults Thinnest skin is on eyelids.

Thickest is on soles, palms,

and elbows. Color is

uniform, except in sun-

exposed areas.

Skin temperature is even

Texture is smooth, soft, and

even.

Skin is resilient. Scalp hair is

shiny, smooth, and resilient.

Nail color is a variation of

pink.

Nail edges are smooth and

rounded.

Callused areas are yellow.

Skin striae, freckles, birth

marks, nevi, and melasma

may be present.

Freckling of buccal cavity,

gums, and tongue is

present in some dark-

skinned persons.

Color hues in dark- skinned

persons are best seen in

the sclera, mucosa, and

nail beds.

Lips and gums are bluish in

dark-skinned persons.

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Life CycleVariations

Normal Findings

Typical Variations

Findings Associated with Disorders

Infants and

children

Newborn skin may be red.

Vernix caseosa is a normal

birth covering.

Newborn nails may need to

be trimmed to prevent

scratching.

At birth, generalized lanugo

suggests prematurity.

Physiologic jaundice is

common.

Primary irritant or

eczematous dermatitis may

cause localized lesions.

Skin roughness may result

from clothing, coldness, or

soap.

Nail shape and opacity vary.

Pigment deposits may be

present in dark-skinned

persons. Darkened nails

may result from antimalarial

drug treatment or shoe

trauma.

White spots in nail plate may

result from mild trauma.

Peeling nails may occur

with water exposure.

Longitudinal ridging and

beading are common.

Newborn skin distortions suggest

masses, nodules, or tumors.

The presence of patches,

erythema, scaling, crusts,

fissures, vesicles, lesions, and

skin irregularities in children

requires investigation.

Localized redness suggests

inflammation.

Hemorrhage results from injury,

steroids, or systemic disorders.

Fluid-filled lesions show red

glow with transillumination.

Generalized lesions may

indicate a systemic disorder,

allergy, or genetic disorder.

Annular patterns are associated

with pityriasis rosea, tinea

corporis and cruris, urticaria.

Connective tissue diseases lead

to changes in skin mobility.

Asymmetric hair loss in males

may indicate a pathologic

condition. Female alopecia or

female hirsutism in male hair

patterns may indicate

pathology. Yellow nails occur

with psoriasis, fungal infections,

and respiratory disease.

Darkened nails can result from

Candida infection or

hyperbilirubinemia. Green-black

nails are caused by

Pseudomonas infection or

subungual hematoma. Nail

depression and clubbing occur

from systemic disease.

Separation of nail plate from

bed results from psoriasis and

infections.

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Life CycleVariations

Normal Findings

Typical Variations

Findings Associated with Disorders

Adolescents Adolescents are prone to

acne from hormonal

changes. Terminal hair

develops at puberty.

Body odors develop.

Perspiration may result from

anxiety or obesity.

Nail hygiene is a clue about

self-care and emotional and

social levels.

Fine or coarse hair and hair loss

may be due to thyroid

conditions.

Pregnant

women

During pregnancy, there are

peripheral vasodilation and

increased capillaries.

Sweat and sebaceous gland

activity increases.

Palmar erythema., a diffuse

redness that covers the

entire palmar surface or the

thenar and hypothenar

eminence, is a common

finding in pregnancy and

usually disappears after

delivery.

Increased pigmentations

occur from hormonal

changes. Pregnancy

causes striae, vascular

spiders, and acne in some.

Vascular spiders and

hemangiomas that are

present may increase in

size.

Older adults Skin becomes more

transparent, pale, dry,

wrinkled, and

hyperpigmented with aging.

Hair becomes coarser with

age.

Nails thicken and become

more brittle with age.

Graying hair occurs as a

result of a decrease in

functioning melanocytes.

Balding patterns in men are

genetically determined.

Several types of lesions

may be present:

Cherry angiomas

Sebaceous hyperplasia

Cutaneous tags/horns

Senile lentigines

Stasis dermatitis and solar

keratosis are skin conditions

that affect older adults. Cardiac

disease influences nail

conditions.

See Box 8-1: Patient Instructions for Skin Self-Examination (p. 174). See cultural differences discussed in the Physical Variations boxes (pp. 171, 176,

177, 191, 200, and 202) and Box 8-2: Cutaneous Manifestations of Traditional Health Practices (p. 176).

See the Mnemonics box for melanoma (p. 215). See Table 8-1 (p. 177), Table 8-2 (p. 177) and Table 8-3 (p. 178), which describe

nevi, moles, and cutaneous color changes.

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See Figure 8-7 (p. 180), Table 8-4 (pp. 183 to 185), Table 8-5 (pp. 186 to 188), and Figure 8-15 (p. 193) for skin lesion and nail drawings.

See Figures 8-10, 8-11, and 8-12 (p. 190) for various patterns of skin lesions. See Box 8-5: Expected Color Changes in the Newborn (p. 195); Risk Factors box:

Hyperbilirubinemia in the Newborn (p. 195); Box 8-6: Skin Lesions: External Clues to Internal Problems (p. 196); and Table 8-7: Estimating Dehydration (p. 199).

See Box 8-7: Staging of Decubitus Ulcers (p. 202). See Table 8-6: Morphologic Characteristics of Skin Lesions (p. 189).

ADVANCED ASSESSMENT OF BREASTS AND AXILLAE

LEARNING OBJECTIVES1. Conduct a history related to the breasts and axillae.2. Discuss examination techniques for the breasts and axillae.3. Identify normal age and condition variations to the breasts and axillae.4. Recognize findings that deviate from expected findings.5. Relate symptoms or clinical findings to common pathologic conditions.

Outline for Chapter 16: Breasts and Axillae

Anatomy and Physiology The breasts are paired mammary glands located on the anterior chest wall,

superficial to the pectoralis major and serratus anterior muscles. In women, the breast extends from the second or third rib to the sixth or seventh rib, and from the sternal margin to the midaxillary line. The nipple is located in the center, surrounded by the areola.

The female breast is composed of glandular and fibrous tissue (which provides support for the breast) and fat (subcutaneous and retromammary) in proportions that vary with age, genetic predisposition, nutritional status, and pregnancy.

The glandular tissue of the breast is arranged into lobes, each composed of lobules of milk-producing acini cells that empty into lactiferous ducts during lactation.

Vascular supply to the breast is primarily through branches of the internal mammary and the lateral thoracic artery.

For purposes of examination, the breast is divided into five segments: four quadrants and the tail of Spence.

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Contraction of the circular and longitudinal muscles in the nipple, induced by tactile, sensory, or autonomic stimuli, causes the milk ducts to empty. Nipple erection is supported by venous stasis in the erectile vascular tissue. Nipples range in color from pink to black.

Each breast contains a lymphatic network (pectoral, subscapular, central, and brachial) that drains the breast radially and deeply.

Age- and Condition-Related Variations Childhood and preadolescence. Childhood and preadolescence represent a latent

phase of breast development when some branching of the primary ducts occurs. Tanner’s five stages of developing sexual maturity in temporal relationship to menarche are useful in assessing breast development. Thelarche (breast development) represents an early sign of puberty in adolescent girls. Breasts develop at different rates, which can result in asymmetry.

Pregnant women. During pregnancy, breasts become soft, loose, and enlarged. They develop darker, wider areolae with Montgomery tubercles. Breasts exhibit a visible network of veins. Colostrum, containing antibodies and other host resistant factors, is produced.

Lactating women. Engorgement is caused by tissue edema and the filling of alveoli and lactiferous ducts. Two to 4 days after delivery, high-protein milk replaces colostrum. By the tenth day, protein decreases and lactose increases; this stabilizes by 1 month. After termination of lactation, breast size decreases, but seldom to prelactation size.

Menopausal and older adults. A moderate decrease in glandular tissue and decomposition of alveolar and lobular tissue occurs before menopause. After menopause, glandular tissue atrophies and is replaced by fat. In older adults, the inframammary ridge thickens, suspensory ligaments loosen, and nipples become smaller, flatter, and less erectile. Skin may become thin and dry, and axillary hair may decrease.

Review of Related History

History of Present Illness Patients with a breast or axilla problem should be asked to describe discomfort,

temporal sequence, relationship to menses, characteristics, nipple retractions, masses and discharges, relationship to external irritants, and enlargement or tenderness in the lymph nodes.

Breast discomfort/pain. Assess temporal sequence, relationship to menses, character (e.g., pulling, burning, drawing, stabbing, aching, throbbing), any associated symptoms or contributory factors, and medications taken.

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Breast mass or lump. Assess temporal sequence, relationship to menses, symptoms such as tenderness or pain, changes in lump, any associated symptoms, and medications taken.

Nipple discharge. Assess character, any associated symptoms, associated factors, and medications taken.

Past Medical History Pertinent data include previous breast diseases, diagnostic tests, surgeries and

treatment, menstrual history, pregnancy and breast-feeding history, risk factors for both benign breast disease and breast cancer risks, and the past use of hormonal and other medications.

Family History Family history should include occurrence of breast cancer or other breast disease

in any relative (male or female). Data should be specific as to age at occurrence, treatment, and results.

Personal and Social History Relevant data include age, cyclic and noncyclic changes in breast characteristics,

menstrual or menopausal status, use of breast support, caffeine intake, alcohol intake, breast self-examination, self-care, use of hormonal medications, and risk factors for cancer.

Age- and Condition-Related Variations Pregnant women. Ask patient about sensations in the breast (fullness, tingling,

tenderness), use of a supportive brassiere, and plans for breast-feeding. Lactating women. Data specific to lactating women include self-care habits,

nursing routines, associated problems, cultural beliefs, diet, and medications. Older adults. Relevant data include occurrence and treatment of skin irritation and

the use of postmenopausal hormone therapy.See Risk Factors: Breast Cancer (p. 497).

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Examination and Findings

Summary of Examination—Breasts and AxillaeBreastsInspection Examine breasts for size, symmetry, contour, skin color and texture, venous patterns,

and lesions. Use several positions for inspection:

Seated, arms hanging loosely at sides Seated, arms extended over head Seated, hands pressed against hips Seated, hands pressed together Leaning forward from the waist

NipplesInspection Examine nipples for symmetry, direction, contour, color, and texture. Mnemonics: Five Ds Related to NipplesBreasts and AxillaePalpation Palpate breasts and axillae with patient in sitting position with arms hanging freely at

sides. Use finger pads and push toward chest in systematic pattern. Use light and then

heavier pressure without lifting fingers. Palpate the tail of Spence in each breast, gently compressing the tissue between your

thumb and fingers. Continue palpation with the patient in the supine position. Have her raise one arm

behind her head and place a small pillow or folded towel under the shoulder. Gently compress the nipple and massage around the areolae. Use palmar finger surfaces to palpate into the axillary hollow for lymph nodes.

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Summary of Breasts and Axillae Findings

Life CycleVariations

NormalFindings

TypicalVariations

Findings Associatedwith Disorders

Adults Breasts are nearly equal in size and bilaterally convex.

Breasts have equal smoothness, contour, and pigmentation.

Slight venous markings are bilateral, and nipples and areolae are bilaterally equal.

Breasts are nontender and nonsuppurative.

Montgomery tubercles are normal.

Breast tissue is dense, firm, and elastic.

Benign, soft, mobile, fluid-filled, bilateral cysts (fibrocystic) may be present.

In some males, breast tissue may be smooth, firm, and mobile (adult gynecomastia).

Breast sizes vary.

Breast pairs may also vary in size.

Striae may be visible. Healthy, large skin pores may resemble pores seen with malignancy. Usual skin markings and nevi may be present.

Carcinoma is suspected when there is peau d’orange color from blocked lymph drainage; nipple inversion, retractions or dimpling; thickened skin and enlarged pores; unilateral inversion; and unilateral venous patterns and nipple discharge.

Red, scaling, crusty patch on nipples suggest ductal cancer.

Bilateral firm, rubbery, mobile masses (fibroadenoma) may suggest malignancy. Tumors of subareolar ducts (papillomas) are suggestive of malignancy. Hard, fixed, single, stonelike mass suggests malignancy.

Infants and

Children

At birth, breasts may be enlarged from maternal estrogen.

Newborns may also have a milky nipple discharge.

Supernumerary nipples may look like moles. Both nipples may be bilaterally inverted.

Montgomery tubercles may be present.

Female prepubertal breast enlargement (premature menarche) may be present.

Adolescents Breasts of female adolescents may be asymmetric.

Breasts develop at different rates, which can result in increased temporary asymmetry.

Boys’ breasts may be enlarged (gynecomastia).

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Life CycleVariations

NormalFindings

TypicalVariations

Findings Associatedwith Disorders

During menstrual cycle, there may be increased nodularity and tenderness.

Pregnant women

Pregnancy causes breast tingling, tenderness, and size increase.

Nipples enlarge and colostrum appears. Venous networks from obesity or pregnancy may be present.

Breasts are more nodular during pregnancy. After delivery, breasts may be hard, warm, reddened, and shiny (engorged).

Breasts are less firm and nipples are darker after lactation.

After termination of lactation, breast size decreases but seldom to prelactation size.

Spider veins may occur on the upper chest.

Particularly during lactation, breasts may become swollen, inflamed, and infected (mastitis).

Older adults Some premenopausal decrease in glandular alveolar and lobular tissue occurs.

After menopause, glandular tissue atrophies and is replaced by fat.

Breasts of postmenopausal women may be flatter, longer, and more relaxed from chest wall.

Breasts of older women are more fine and granular.

Menopausal women may experience blocked subareolar ducts (mammary duct ectasia).

Firm, discolored, irregular mass can result from fat necrosis in response to local injury.

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See Box 16-1: Breast Self-Examination (pp. 498 and 499); Box 16-2: Screening for Breast Cancer (p. 500); and Box 16-4: Examining the Patient Who Has Had a Mastectomy (p. 511).

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc

Course Lecture Content:

Dermatological System; Breasts and Axillae:• Advanced assessment of the dermatological system, breasts, and axillae• Assessment findings of abnormal presentations in the

dermatological system, breasts, and axillae• Differential diagnoses of the dermatological system,

breasts, and axillae

Christopher W. Blackwell, Ph.D., ARNP-CAssistant Professor, School of NursingCollege of Health & Public AffairsUniversity of Central FloridaNGR 5003: Advanced Health Assessment & Diagnostic Reasoning

Advanced Assessment of Dermatological System Anatomy and Physiology: Skin protects against infection and invasion/ minor trauma Retard body fluid loss through mechanical barrier Regulate body temp though radiation, conduction, convection, and evaporation Sensory perception via nerve endings Produce vitamin D Help regulate BP through constriction of skin blood vessels Repair surface skin wounds Excrete sweat, urea, and lactic acid Express emotions Epidermis: Outermost layer, consists of stratum corneum and cellular stratum

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Connects to the dermis via the basement membrane Dermis: Vascular connective tissue layer supporting and separating epidermis from SQ

adipose Sensation of pain, temperature, and touch received in dermis Hypodermis: SQ layer, rich with connective tissue and adipose cells Appendages: Eccrine sweat glands, spocrine sweat glands, sebaceous glands Vellus and terminal hair Nails: eponychium, nail bed, nail plate, paronychium, lunula, cuticle

Advanced Assessment of Dermatological System Infants and Children: Skin smoother due to absence of terminal hair and exposure Vernix caseosa covers the child at birth SQ layer undeveloped, leading to potential hypothermia Newborn covered with fine silky hair called lanugo (shed within 10-14 days after

birth); eccrine glands function within a month (no apocrine function) Adolescents: Apocrine glands enlarge and become active Androgen stimulates sebum production, increasing oily skin and acne Pregnant Women: Blood flow increases to skin from inc. in # of capillaries and vasodilation (spider

hemangiomas/ telegenctasia); sebaceous gland activity inc.; fragility of tissues increases due to elastin (separation); pigment increases on face, nipples, areolas, vulva, perianal skin, and umbilicus

Older Adults: Sebaceous/sweat gland activity decreases (xerosis) Dermis becomes less elastic, losing collagen and elastic fibers Wrinkling increases due to lifelong sun exposure Functioning melanocytes decrease, graying the hair Terminal hair begins to soften to vellus, vellus coarsens to terminal

Advanced Assessment of Dermatological System Anatomic Structure of the Skin Advanced Assessment of Dermatological System

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Review of Related Hx: Hx of Present Illness: Skin: Changes in dryness, pruritus, sores, rashes, lumps, discolorations, changes in

lesions, non-healing areas Temporal sequence: date of onset (sudden/gradual), time sequence of

occurrence/development, date of recurrence Location: skinfolds, extensor/flexor surfaces, local/general Associated Symptoms: presence of systemic disease, fever, sweats, chills,

stress/leisure activity Recent exposure to drugs, environmental/occupational toxins, others w/ skin

conditions Patient’s perception of cause Travel Hx: where, when, length of stay, exposure to environment/people/diseases Self-treatment, response, aggravating/alleviating factors Affects on ADL, self-concept, etc. Rx: topical or systemic; nonRx/Rx Hair: Changes in loss, growth, distribution, texture, color Occurrence: sudden/gradual, symmetric vs. asymmetric patterns, recurrent Associated symptoms: pain, itching, lesions, systemic diseases, fever, physiologic/

psychological stress Exposure to Rx, environmental/occupational chemicals, commercial hair care

products Nutrition: Lipid deficiency; dietary changes/dieting Self-treatment, response, aggravating/alleviating factors Affects on self-concept, etc. Rx: Rx/Non-Rx; hair loss Tx (Propecia, Minoxidil, etc.)

Advanced Assessment of Dermatological System Nails: Changes: splitting, breaking, discoloration, ridging, thickening, markings,

separation from nail bed Recent Hx: systemic illnesses/fever, trauma, psych/physiologic stress Associated pain, edema, exudate Temporal: sudden or gradual onset, relationship to injury of nail/finger

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Recent exposure to Rx, environmental/occupationa; chemicals, frequent immersion in water

Self-treatment, response, aggravating/alleviating factors Rx: Rx/NonRx Past Medical Hx: Skin: Previous conditions/problems, allergic reactions (describe lesion), Tx;

tolerance to sunlight, diminshed/heightened sensitivity to stimuli; cardiac, respiratory, hepatic, endocrine, or other systemic diseases

Hair: Previous problems, loss, thinning, usual growth/distribution, brittleness, breakage, Tx; systemic problems (thyroid/hepatic disorder, severe illness, malnutrition, skin disorder)

Nails: Previous problems/injury (bacteria/fungi/virus); systemic problems (associated skin disorder, congenital anomalies, respiratory, cardiac, endocrine, hematologic, or other systemic disease

Advanced Assessment of Dermatological System Family Hx: Current/past dermatological diseases, melanoma/CA, pruritus,

allergies, bacterial/fungi/viral infections; hereditary allergic diseases (asthma/hay fever); familial loss or hair coloration patterns

Personal and Social Hx: Self-care: soaps, oils, lotions, cosmetics, home remedies/preparations, sun

exposure/protection patterns, recent changes in self-care Assess monthly performance of SSE (8-1) Hair care habits: cleaning routine, shampoos/rinses used, coloring preparations,

perms, recent changes in care Nail care habits: difficulty in clipping nails; instruments used; biting Exposure to environment/occupation toxins (dyes, chemicals, plants, toxins,

frequent immersion of hands in water, sun exposure) Psych/physiologic stress; Use of ETOH; Smoking/recreational drugs Infants: Feeding Hx (breat/bottle, type of formula, what/when foods introduced Diaper Hx: type of diaper used, skin cleaning routines, use of rubber pants,

washable diapers (how cleaned) Types of clothing and washing practices (soap, detergents, new blanket/clothing) Bath practices (soaps, oils, lotions) Dress Habits: amount and type of clothing related to environmental temp Temp and humidity of home environment (AC/heat/humidification) Rubbing head against mattress, rug, furniture, wall

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Advanced Assessment of Dermatological System Children: Eating habits: food allergens; chocolate, candy, soft drinks, bubble gum Allergies: eczema, urticaria, pruritus, hay fever, asthma, chronic resp. disorders Pet/animal exposure; outdoor exposures from playing, hiking, camping, picnics Skin injury Hx: frequency of falls, cuts, abrasions, unexplained injuries Chronic manipulation of hair/nail biting Pregnant Women: Weeks of gestation/postpartum Hygiene practices; exposure to irritants; presence of skin problems before

pregnancy (acne tends to worsen) Effects of pregnancy on preexisting conditions: psoriasis may remit; condylomata

acuminata become longer and more numerous Older Adults: Increased/decreased sensation to touch/environment Generalized chronic pruritus: exposure to skin irritants, detergents, lotions (w/

high ETOH content), woolen clothing, humidity of environment Susceptibility to skin infectionsl healing responsesl frequent falls resulting in

hematomas/ cuts/abrasions Hx of DM or PVD; hair loss Hx (gradual vs. sudden; symmetric vs. asymmetric

loss pattern)

Advanced Assessment of Dermatological System Examination and Findings: Skin: Inspection: Adequate lighting is essential; daylight best for color detecting Examine the entire body: assess distribution and extent of lesions, symmetry of

body surfaces, detect different body areas, and compare sun-exposed to non-sun-exposed areas

Remove all clothing (provide privacy); pay careful attention to intertriginous surfaces, especially in bed-riddin and older clients

Assess for presence of lesions, color and uniform thickness, symmetry, hygiene Skin thinnest on eyelids, thickest soles, elbows, and palms; not callusing on hands

and feet Darker skin expected around knees and elbows

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Nevi present in everyone; differing locations; may be flat, slightly raised, dome-shaped, smooth, rough, or hairy (tan, gray, shades of brown-to-black); Most harmless—may be dysplastic, pre/cancerous

Cancerous nevi appear on the upper back in men and legs in women Cholama (mask) on face common in pregnancy Color- hues in dark persons best seen in sclera, conjunctiva, buccal mucosa,

tongue, nail beds, and palms Hyperpigmented macules normal on soles of feet; freckling normal in buccal

mucosa, gums, and tongue; slight bluish color to lips/gums normal in dark-skinned; muddy sclera

Abnormal Dermatological Presentations Pathological Vascular Skin Lesions Advanced Assessment of Dermatological System Palpation: Palpate for moisture, temperature, texture, turgor, and mobility Dampest areas on the scalp, forehead, and axillae Assess intertriginous areas carefully for cutaneous candidiasis Skin should be cool-to-warm to touch; texture smooth, soft and even; widespread

roughness may be kyperkeratosis, also occurs from arsenic/toxin exposure Skin should return to baseline < 2 sec for turgor (assess clavicle) Skin Lesions: Lesions are primary (spontaneous) or secondary (result from trauma to a lesion) Describe lesions (size, shape, color, texture, elevation/depression, pedunculation)

according to exudate (color, odor, amt., consistency); configuration (annular, grouped, linear, arciform, diffuse), and location/distribution (generalized/localized, region of the body, patterns of discreetness or confluent)

Measure lesions precisely (ht/width/depth—in cm); no household item comparisons

5-10 power lamp helpful for detailed lesion inspection Transillumination helpful to examine fluid in cysts/masses Wood’s lamp useful to distinguish fluorescing lesions (fungus)

Abnormal Dermatological Presentations Primary Skin Lesions Macule: Flat, circumscribed area at color change; <1cm (Measles)

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Papule: Elevated, firm, circumscribed area; <1cm (Verruca) Patch: Flat, nonpalpable irregular macule <1cm (Vitiligo) Abnormal Dermatological Presentations Plaque: Elevated, firm, rough lesion w/ flat top; >1cm (psoriasis) Nodule: Elevated, firm; deeper in dermis than papulae; 1-2cm diam (lipoma) Wheal: Eleveated, irregular-shaped area of cutaneous edema (urticaria)

Abnormal Dermatological Presentations Tumor: Elevated and solid lesion deeper in dermis; > 2cm diameter (lipoma) Vesicle: Elevated, circumscribed, superficial, not in dermis; filled with serous fluid; <1 cm (varicella) Bulla: Vesicle > 1cm (blister) Abnormal Dermatological Presentations Pustule: Elevated, superficial lesion, similar to vesicle but purulent (impetigo) Cyst: Elevated, circumscribed; encapsulated, in dermis/SQ layer filled with fluid/semi-sold material (acne) Telangectasia: Fine, irregular, red lines; vasodilitation (rosacea) Abnormal Dermatological Presentations Scale: Heaped-up, keratinized cells; flaky skin; thick/thin dry/ oily (seborrheic dermatitis) Fissure: Linear crack/break from

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epidermis to dermis (tinea pedis) Erosion: Loss of part of the epidermis; follows vesicle rupture

Abnormal Dermatological Presentations Ulcer: Loss of epidermis and dermis; concave (decubitus) Crust: Dried serum, blood, or purulent exudate (eczema) Atrophy: Thinning of skin surface and loss of skin; translucency (striae)

Advanced Assessment of Dermatological System Hair: Palpate for texture; inspect for color, distribution, and quantity Palpate for dryness/brittleness; could indicate systemic disease Hair loss to feet/toes could indicate PVD Presence of scarring at loss good diagnostic key Asymmetric hair loss indicates problem Male pubic: upright triangle; female upside down Hirsutism in a female could be androgen excess Nails: Inspect for color, length, configuration, and cleanliness Nail bed should be variations of pink Sudden appearance of white lines in nails, r/o melanoma Yellowing consistent with onychomycosis Single black/blue nail could be hematoma/melanoma Look for nail ridging, grooves, deformity, and ptting Nail depressions typically result from syphilis, high fevers, PVD, and uncontrolled

DM Nail bed should measure 160o; clubbing >180o (Schamroth technique), associated

with resp/CV disease, cirrhosis, cellulitis, thyroid disease (feels boggy) Nail plate should feel hard and smooth w/ uniform thickness; nail separation from

bed common in psoriasis, trauma, candidal, or Pseudomonas infection

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Advanced Assessment of Dermatological System Schamroth Technique

Abnormal Dermatological Presentations Pathological Nail Presentations Advanced Assessment of Dermatological System Infants and Children: First few hours of life, newborn is red Physiologic jaundice mildly present in up to 50%; should subside in 3-4 weeks If jaundice extends below nipples, bilirubin excessively high Assess newborn carefully over spine, midline of head, nape of neck to bride of

nose, and neck to ear (sinus tracts; clefts; cysts) The older the baby, the more simian creases (Down’s Syndrome) Transient puffiness in hands, feet, eyelids, legs, pubis, sacrum normal in some

newborns; disappears in 2-3 days Cyanosis of the hands and feet present at birth through several days; if persists,

suspect cardiac disease Mongolian spots (normal) occur in dark-skinned; bluish-black-to-gray; disappear

in preschool years Milia common during 1st 2-3 months (clogged sebaceous glands) Sebaceous hyperplasia (tiny yellow macules/papules) common forehead, cheeks,

nose, and chin; disappear at 1-2 months Best to assess turgor by pinching skin on ABD; excessive dryness/moisture rarely

significant in children Dennie-Morgan fold common flap of skin above eye, results from chronic rubbing Advanced Assessment of Dermatological System Adolescents: Same exam as an adult; hair and skin oiliness normal; address

concerns about acne Pregnant Women: Striae gravidarum normal to occur ABD, thighs, and breasts;

fade but never disappear; telangiectasias on face; most epidermal tags resolve; linea nigra; cholasma in 70%; pruritus w/o rash over ABD and breasts common; hair loss w/ shedding 2-4 months after delivery common; acne inc. in 1st trimester, declines by 3rd

Older Adults: Normally transparent and paler in light-skinned individuals w/ inc. freckling; flaking and scaling on EXTs, turgor not reliable for hydration; assess for breakdown at heels, sacrum, elbows, scapulae, occiput; wrinkling and small areas of purpura normal; cherry angiomas, seborrheic keraotosis, sebaceous

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hyperplasia, cutaneous tags/horns, senile lentigines all normal

Abnormal Dermatological Presentations Corn: Results from friction forces thickening of skin; common in

interdigital spaces of toes Callus: Superficial area of hyperkeratosis Eczematous Dermatitis: Most common inflammatory disorder; acute, subacute,

chronic

Abnormal Dermatological Presentations Furuncle: Small perifollicular pustular nodule (staph) Folliculitis: Staph infection of hair follicle; small pustules Abnormal Dermatological Presentations Cellulitis: Diffuse, acute, strept/staph infection; red, hot, tender, indurated

streaking Tinea: Fungal infection, typically angular (corporis, cruris, capitis, pedis, unguim) Abnormal Dermatological Presentations Pityriasis Rosea: Primary oval or round plaque with superficial scaling on

EXT/trunk; parallel alignment w/ ribs Psoriasis: Well-circumscribed, dry, silvery, scaling papules and plaques Abnormal Dermatological Presentations Rosacea: Telangiectasia, erythema, papules, and pustules on central face Drug Eruptions: Discrete/confluent erythematous maculopapules on trunk, face,

EXT, palms, and soles Abnormal Dermatological Presentations Herpes Zoster: Varicella infection; single dermatome consisting of red, swollen

plaques, vesicles become filled w/ purulent fluid Herpes Simplex: Grouped, painful erosions/ulcer; forms crust (type 1 oral; type 2

genital)

Abnormal Dermatological Presentations Basal Cell Carcinoma: Most common; race, ears, neck, scalp, shoulders, and back Abnormal Dermatological Presentations Squamous Cell Carcinoma: Malignant tumor arising from epidermis; scalp, back

of hands, lip* and ear*; base could be inflammed *- Most vulnerable areas

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Abnormal Dermatological Presentations Malignant Melanoma: Develops from melanocytes ABCDE Rule: Asymmetry; Borders; Color; Diameter; Elevation

Abnormal Dermatological Presentations Kaposi Sarcoma: Malignant tumor of the endothelium: soft, bluish-purple,

painless; immunocompromise (HIV) Abnormal Dermatological Presentations Alopecia Areata: Sudden, rapid onset of hair loss (shaft poorly developed and

breaks) Traction/Scarring Alopecia Abnormal Dermatological Presentations Paronychia: Redness, swelling, and tenderness at lateral nail folds Tinea Unguium: Yellow, hardening of nail due to fungus Ingrown Nails: Nail pierces nail fold and grows into dermis Subungal Hematoma: Blood collects under the nail plate until nail grows out. Leukonychia Punctata: White spotting under the nail (from injury) Habit-tic Deformity: Horizontal sharp grooving in band extending to tip of nail Onycholysis: Loosening of the nail plate with separation from bed Koilonychia (spooning): Fe-deficiency, anemia, syphillis, fungal infection causes

concavity of nail Beau Lines: Coronary occlusion, hypercalcemia, or dkin disease causes sharp

lateral lines in nail Terry Nails: Cirrhosis and hypoalbuminemia causes transerve white band over

nails Psoriasis: Pitting, onycholysis, and subungual thickening Warts: Epidermal neoplasms cause by virus Digital Mucous Cysts: Groove in nail plate w/ jelly-like filled cysts at tip

Abnormal Dermatological Presentations Pregnant Women: PUPP Herpes Infants and Children: Café-Au Lait Patches: > 5 patches w/ diameter > 1cm in children <5 indicates

neurofibromatosis; treat as suspicious Seborrheic Dermatitis: erupts in scalp (craddle cap), back, intertriginous areas, and

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diaper Miliaria: Irregular, red, macular rash w/ occlusion of sweat glands Impetigo: Highly contagious staph infection; honey-colored crusts; exudative Acne Vulgaris: Inflammed lesions of acne w/ sebum and comedone formation Reddened Patchiness: Red lesions on capillary bed on upper eyelids, forehead, and

upper lip; disappear at 1 Varicella: Chickenpox; fever, mild malaise, and pruritic maculopapular skin

eruption which becomes vesicular; scalp and trunk start spread to EXT Measles: Rubeola; highly-communicable viral w/ prodromal fever, conjunctivitis,

coryza, and bronchitis, followed by red blotchy rash, lasting 4-7 days; complications of respiratory tract and CNS

German Measles (Rubella): Light pink to red maculopapular rash; rash on face an trunk quickly papules and fades within 3 days; reddish spots on palate

Physical Abuse: Bruises (cord, belts, prior to mobile is concern); Lacs (oral—forced feeding, bites); Burns (scald/stocking glove distribution; hair loss

Older Adults: Stasis Dermatitis (associated w/ PVD; cellulitis, erosion, and scaling); Solar Keratosis (raised, erythematous lesion <1cm; premalignant)

Advanced Assessment: Breasts & Axillae Anatomy and Physiology: Superficial to pectoralis major & serratus anterior Composed of glandular/fibrous/SQ/retromammary fat 15-20 lobes/breast; each lobe 20-40 lobules w/ milk-producing acini cells

emptying into lactiferous ducts Coopers ligaments extend through breast and anchor to muscle fascia Vascular supply via internal mammary gland and lateral thoracic artery (deep

tissue); IC arteries feed superficial arteries For exam, breast divided into upper/lower-inner, upper/lower-outer qdts Tail of

Spence Contraction of smooth muscles in nipple erects nipple and empties lactiferous

ducts Lymphatics drain breast radially and deeply; superficial drain skin and deep drain

mammary lobules Axillary nodes easily palpable when enlarged; pectoral nodes located in lateral

axillary fold, central nodules high in axilla, subscapular nodes at border of scapula deep in posterior axillary fold, brachial nodes upper humerus

Menarche typically 2 years s/p breast buds Breasts can enlarge 2-3 times normal from luteal and placental hormones; alevoli

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engorge, tissue becomes softer/looser, colustrum accumulates; veins highly visible Colostrum secreted in 1st few days after delivery—more protein/minerals/ATB

than milk; involution occurs 3 months after breastfeeding cessation; breast size usually larger

Older women have more loose breasts due to relaxation of Coopers ligaments and decrease in glandular tissue w/ decomposition of lobular tissue; nipples smaller, flatter, and lose erectile function

____________________________________________________________________ Advanced Assessment: Breasts & Axillae Review of Related Hx: Hx of Present Illness: Breast pain: onset gradual/sudden; length of symptoms, come and go or persist;

relation to menses timing/severity; character (stinging, burning, stabbing, aching, throbbing, uni/bilateral; localization, radiation); associated s/s (lump, mass, DC, inframammary skin irritation due to repeated skin-skin/brassiere contact; strenuous activity/injury); Rx Hx

Mass or lump: Temporal (length of time when 1st noted, come/go or persist—relation to menses); symptoms (tenderness/pain, dimpling, changing in contour); Rx Hx

Nipple DC: character (spontaneous/provoked, uni/bilateral, gradual/sudden onset, duration, amt, color, consistency, odor; associated symptoms (nipple retraction, breast lump, discomfort); associated factors (relationship to menses or other activity; recent injury) Rx hx (contraceptives, phenothiazines, digoxin, diuretics, steroids)

Advanced Assessment: Breasts & Axillae Anatomy/Lymphatic Flow of Breast Advanced Assessment: Breasts & Axillae Past Medical Hx: Previous breast disease (CA, fibrocystic) Known BRCA1/2 mutation; other hereditary symptoms (hereditary nonpolyposis

colorectal CA; Li-Fraumeni/Cowden syndrome) Previous CA (ovarian, colorectal, endometrial) Surgeries (breast biopsy, aspirations, implants, reductions, plasties,

oophorectomy) Changes in breast characteristics (pain, tenderness, lumps, DC, skin changes,

shape changes) Changes with menses (tenderness, swelling, pain, enlarged nodes) Mammography Hx (how frequent, last exam, results)

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Menstrual Hx (1 day of LMP, age of menarche/pause, cycle length, amt of flow, regularity, associated breast symptoms (nipple DC, pain, discomfort)

Pregnancy: age at each pregnancy, length of each preg, date of delivery/termination

Lactation: # of children breast-fed, duration of feeding time, date of cessation of feeding, Rx to suppress lactation

Menopause: age of onset, course, associated problems, residual problems Use of hormonal Rx (name, dosage, route, reason for use—contraception,

menstrual control, menopausal symptom relief, length of prescription, date of termination); other Rx (Tamoxifen/Raloxifene)

Advanced Assessment: Breasts & Axillae Family Hx: Breast CA (primary/secondary relatives, type of cancer, age of time of occurrence;

Tx/results; BRCA1/BRCA 2 mutation Other CA (ovarian, colorectal, known hereditary cancern syndromes—discussed) Other breast diseases (female/male relatives—types of disease, age at time of

occurrence, Tx/results) Personal/Social Hx: Age, breast support w/ strenuous activity, sports, exercise;

amt of caffeine intake, BSE (frequency—timing in menstrual cycle); use of ETOH Pregnant Women: Sensation/fullness, tingling, tenderness; presence of colustrum

and knowledge of self breast care; use of supportive brassiere; knowledge of breastfeeding; plans to breastfeed, expectations (all women should be encouraged to breastfeed)

Lactating Women: Cleaning procedures (soap products can dry out breasts); frequency of use nipple preparation; use of nursing brassiere; nipple tenderness, cracking, pain, retraction; problems w/ feeding; associated problems (engorgement, leakage, localized tenderness, lumping—indicates plugged duct), fever, infection, Tx/results, infant w/ oral candidiasis; nursing routine (length of feeding, frequency, rotation of breasts, positions used); breast milk pumping devices used, frequency; cultural beliefs about nursing; food and environmental agents that can affect breast milk (chocolate, photo chemicals), Rx that cross milk-blood barrier (cimetidine, clemastine, thiouracil—all Rx should be evaluated for potential newborn effects

Older Adults: Skin irritations from tissue-to-tissue contact or rubbing of brassiere; Tx; hormone Tx during or since menopause (name and dosage, diuration of Tx)

Advanced Assessment: Breasts & Axillae

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Examination and Findings: Disrobe both breasts to the waist; be matter-of-fact Inspection: Have pt sit w/ arms hanging loosely at sides, inspect each breast and compare w/

other for size, symmetry, contour, skin color, texture, venous patterns, and lesions Lift breasts with fingertips–determine if any changes Conical, convex, pendulous, large pendulous Skin should appear smooth and contour uninterrupted Retractions and dimpling could indicate CA Peau d’ orange results from edema caused by blocked lymph draining or advanced

CA Venous patters should be bilatterally similar; unilateral visible veins could indicate

feeding to a CA tumor; bilateral typically OK Recent change in any lesion ALWAYS warrants further study

Advanced Assessment: Breasts & Axillae Breast Morphology Advanced Assessment: Breasts & Axillae Areola should be round or oval, bilat equal Color ranges from pink to black Areola typically darkens during preg and remains so Retraction is seen as flattening, withdrawal, or inversion of the nipple (indicates

inflammation/CA) Change in axis of the nipple could result from cancerous tumor tissue pulling Nipple color should match areola; surface may be smooth or wrinkled, but free of

cracking, crusting, or DC Supernumerary nipples follow the mammary ridge and are typically mistaken for

nevi Reinspect in various positions Advanced Assessment: Breasts & Axillae Inspection Positions

Advanced Assessment: Breasts & Axillae Palpation: Palpate breasts, axillae, supra/infra clavicular regions Seated Palpation: Chest Wall Sweep: Palm of hand “sweeps” from clavicle to nipple

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Bimanual Digital: Compress tissue between flat-handed fingers, with one hand securing the floor of breast

Lymph Node Palpation: Flex arm at elbow, support L arm w/ your L hand and palpate w/ your R finger pads; push firm; roll tissue downward, exploring all areas of axillae; also palpate supra/infra clavicular nodes, rotating entire supraclavicular fossa—have pt. turn head towards palpated side and lift that shoulder; palpate Virchow’s nodes down SCM muscle while pt. tilts chin to chest lightly (THESE NODES FIRST TO REFLECT CA OF ABD/THORAX—SENTINEL NODES

Describe nodes’ location, size, shape, consistency, tenderness, fixation, delineation of borders

Advanced Assessment: Breasts & Axillae Seated Position Palpation Techniques Sweep Bimanual Digital Axilla

Advanced Assessment: Breasts & Axillae Supine Palpation: Pt. raises hand above head, place a folded towel under that shoulder to spread

breast tissue Palpate each breast separately Palpate all areas of breast tissue (including tail of Spence) for lumps or nodules Palpate using finger pads; push in gently firm, rotate counter/ clockwise Use either vertical strips, concentric circles, or tire-spoke: End at nipple and compress if DC present; note dimensions, consistency, and

mobility of any palpable lesions

Advanced Assessment: Breasts & Axillae Special Populations: Breast tissue in women should feel dense, firm, and elastic; lobular tissue is like

widely-dispersed tiny granular bumps A firm transverse ride of breast tissue is felt at inframammary ridge—not a mass Normal for the newborn to have enlarged breasts from passed estrogen for a

relatively short time after birth; disappears by 3 months; Witch’s Milk R/L breasts may not develop at same time in adolescents Adolescent males sometimes have a normal subareolar mass Most breast changes in pregnancy are noticeable during the 1st trimester; nipples

may flatten/invert; crusted colostrum may appear on nipple; striae/hyperpigmentation/spider veins normal

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Engorged breasts feel warm, firm, dense, and are shiny and painful

Clogged ducts create a tender spot that is hot and lumpy; apply heat, continue to nurse, and expectorate milk; assess cracking/trauma

Breasts in postmenopausal women flattened, elongated, and suspended more loosely from chest wall; granular feel to palpation; no longer necessary to time BSE w/ menses—pick one day out of the month; HRT can result in painful, fluid-filled cysts

Abnormal Presentations: Breasts/ Axillae Fibrocystic Changes: Benign cyst formation caused by ductal enlargement Associated w/ long follicular/luteal phases of cycle Differential Dx: Breast Masses Fibroadenoma: Benign tumors of stromal/epithelial elements—hyperplastic or proliferative

process in a single duct; asymptomatic w/o change w/ menses; rare in older women (SUSPECT CA); slight risk of becoming CA

Malignancy: Peak between 40-75 years; majority > 50; 80% present w/ a painless lump; mass

or thickening of the breast, marked asymmetry of breasts, prominent unilater veins; discolorations, peau d’ orange, ulcerations, dimpling, puckering (retraction), fixed inversion of nipples

Fat Necrosis: Firm, irregular mass due to localized trauma Intraductal Papillomas: Benign 2-3 cm tumors of subareolar ducts—tend to have

serous/sanginous DC; biopsy for CA Paget Disease: Surface manifestation of underlying CA; red, scaling crust on

nipple, areola, surrounding skin (unilaterally—rules out eczema) Adult Gynecomastia: Breast tissue development in males (testicular/pituitary-

hormones/liver failure/antiHTNive Rx w/ estrogens/steroids Retention Cysts: Inflammation of sebaceous glands of areola; tender and

suppurative Galactorrhea: Lactation not associated w/ childbearing (prolactin-secreting

tumors, hypothyroid, Cushing, hypoglycemia) Premature Thelarche: Premature development of breasts (typically bilateral) Mastitis: Swelling, tenderness, erythema, and heat from infection (chills, swets,

fever, tachycardia) Mammary Duct Ectasia: Bilateral pain, tenderness, inflammation, spontaneous,

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sticky, multicolored nipple DC

Abnormal Presentations: Breasts/ Axillae Fibrocystic Breasts Fibroadenoma Abnormal Presentations: Breasts/ Axillae Malignancy Fat Necrosis Abnormal Presentations: Breasts/ Axillae Intraductal Papillomas Paget Disease Abnormal Presentations: Breasts/ Axillae Mastitis Mammary Duct Ectasia Differential Dx: Breast Masses

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