Breast (1) (History and examination) Flashcards
breast lump history: introduction
- Wash your hands and don PPE if appropriate.
- Introduce yourself to the patient including your name and role.
- Confirm the patient’s name and date of birth.
- Explain that you’d like to take a history from the patient.
- Gain consent to proceed with history taking.
breast lump history: presenting complaint
- ‘What has brought you to see me today?’
breast lump: history of presenting complaint
- SOCRATES
- Key symptoms to ask about
- Nipple discharge or bleeding (mastitis and breast cancer)
- Nipple inversion (breast cancer)
- Erythema (breast abscess, mastitis and underlying breast cancer)
- Ulceration (breast cancer)
- Dimpling (peau d’orange) (breast cancer)
- Fever (breast abscess)
- Weight loss (breast cancer)
- Malaise (breast abscess and breast cancer)
- Lymphadenopathy (axilla and neck)
- Bone pain (metastasis)
breast lump: systemic enquiry
- Systemic: fevers (e.g. breast abscess)
- Respiratory: shortness of breath (e.g. lung metastases)
- Gastrointestinal: abdominal pain, nausea and vomiting (e.g. bowel obstruction)
- Neurological: confusion (e.g. brain metastases)
- Musculoskeletal: back pain (e.g. spinal metastases)
breast lump: PMH
- Are you currently seeing a doctor for anything?
- Any other conditions?
-
Obstetric and gynaecology history (RF for breast cancer)
- Early menarche
- Late menopause
- Treatment with continuous combined hormone replacement therapy
- Not having breastfed
breast lump: Fx
- Breast bowel or ovarian cancer
- Clarify what age these diseases developed
- Fx of BC in a first-degree relative is a signif risk factor
- Genetic mutations: BRCA1, BRCA2 and TP53
breast lump: Dx
- Prescribed
- Over the counter
- contraception history
breast lump: allergies
always ask about allergies
breast lump: social history
- General social context
- Type of accom
- Who they live with
- ADR
- Carer input
- Smoking
- pack-years = [number of years smoked] x [average number of packs smoked per day]
- one pack is equal to 20 cigarettes
- Alcohol (signif RF)
- Occupation
breast lump: closing
- Summarise key point
- Ask if any questions or concerns
- Thank patient
- Dispose of PPE
breast examination: intro
- Wash your hands and don PPE if appropriate.
- Introduce yourself to the patient including your name and role.
- Confirm the patient’s name and date of birth.
- Briefly explain what the examination will involve using patient-friendly language: “Today I’ve been asked to perform a breast examination. The examination will involve me first inspecting the breasts, then placing a hand on the breasts to assess the breast tissue. Finally, I’ll examine the glands of your neck and armpit.”
- Explain the need for a chaperone: “One of the female ward staff members will be present throughout the examination, acting as a chaperone, would that be ok?”
- Check if the patient understands everything you’ve said and allow time for questions: “Does everything I’ve said make sense? Do you feel you understand what the examination will involve? Do you have any questions?”
- Gain consent to proceed with the examination: “Are you happy for me to carry out the breast examination?”
- Position the patient sitting upright on the side of the bed.
- Ask the patient to undress down to the waist to adequately expose their breasts for the examination. Provide the patient with privacy to get undressed and offer a blanket to allow exposure only when required.
- If the patient has presented due to concerns about a lump, ask about its location. This can be helpful during initial inspection and when palpating the breasts as you should always begin palpation on the asymptomatic breast.
- Ask the patient if they have any pain before proceeding with the clinical examination.
breast exam: inspection
With the patient sitting on the side of the bed ask them to place their hands on their thighs to relax the pectoral muscles.
Inspect the breasts looking for:
- Scars: these may indicate previous breast surgery such as lumpectomy (small scar) or mastectomy (large diagonal scar).
- Asymmetry: this can be helpful in identifying abnormalities via comparison, however, it should be noted that breast asymmetry is a normal feature in most women.
- Masses: note any visible lumps that will require further assessment.
- Nipple abnormalities: these can include nipple inversion and discharge.
- Skin changes: including scaling, erythema, puckering and peau d’orange.
nipple changes
-
Inversion
- Normal in lots of women
- If develops without clear precipitant think breast cancer, abscess etc
-
Discharge
- Usually benign e.g. pregnany
- Less commonly associated with mastitis or breast cancer
skin changes
-
Scaling
- Pagets disease of the breast(associated with underlying in-situ pr invasive carcinoma of the breast)
-
Erythema
- Mastitis, abscess
- Fat necrosis due to trauma
- Breast cancer
-
Puckering
- Malignancy can cause ligamentous contraction which draws the skin inwards
-
Peau d’orange
- Occurs due to cutaneous lymphatic oedema
- Tethering of swollen skin to hair follicles and sweat glands- dimples
- Inflammatory breast cancer
Manoeuvres
- Hands pushing into hips
- Repeat inspection with the patient pressing their hands into their hips to contract the pectoralis muscles.
- If a mass is visible, observe if it moves when the pectoralis muscle contracts which suggests tethering to the underlying tissue (e.g. invasive breast malignancy).
- The manoeuvre may also accentuate puckering if a mass invading the suspensory ligaments of the breast is also tethered to the pectoralis muscle.
2. Arms above the head whilst leaning forwards
- Finally, complete your inspection by asking the patient to place their hands behind their head and lean forward so that the breasts are pendulous.
- This position exposes the entire breast and will exaggerate any asymmetry, skin dimpling or puckering.
Breast palpation
- Adjust the head of the bed to 45° and ask the patient to lie down. Begin palpation on the asymptomatic breast first and then repeat all examination steps on the contralateral breast. Ask the patient to place the hand on the side being examined behind their head to fully expose the breast.
- A systematic approach to palpation is essential to ensure all areas of the breast are examined. There are several different techniques all of which are equally appropriate if you perform them correctly:
- Clock face method: view the breast as a clock face and examine each ‘hour’ from the outside towards the nipple.
- Spiral method: begin palpation at the nipple and work outwards in a concentric circular motion.
- Quadrants method: divide the breast into quadrants and examine each thoroughly.
Use the flats of your middle three fingers to compress the breast tissue against the chest wall, as you feel for any masses. If a mass is detected, assess the following characteristics:
- Location
- Which quadrant is the mass located
- How far from the nipple
- Size
- Approximate dimension sof mass
- Shape
- Shape of mass
- Consistency
- Smooth
- Firm
- Stony
- Rubbery
- Mobility
- Does it move feely
- Does it move with the overlying skin
- Does it move with pectoral contraction
- Fluctuance
- Hold mass by its sides then apply pressure to the centre of the mass with another finger
- If the mass if fluid-filled e.g. a cyst then you should feel the sides bulging outwards
- Overlying skin changes
- Erythema
- puckering
Axillary tail
The axillary tail is a projection of breast tissue that begins in the upper outer quadrant of the breast and extends into the axilla. The majority of breast cancers develop in the upper outer quadrant so it’s essential this area is examined thoroughly.
Nipple-areolar complex
Use the flats of your middle three fingers to compress the areolar tissue towards the nipple as you inspect for any nipple discharge.
If there is a history of nipple discharge, but none is visible, ask the patient to attempt to express discharge from the nipple (if they are comfortable to do so) and assess the characteristics of the discharge:
- Colour (e.g. blood-stained, green, yellow)
- Consistency (e.g. thick, watery)
- Volume
Elevate the breast
Lift the breast with your hand to inspect for evidence of pathology not visible during the initial inspection (e.g. dimpling, skin changes).
Lymph nodes
Palpate the regional lymph nodes which are responsible for lymphatic drainage of the breast to identify evidence of breast cancer metastases. Enlarged, hard, irregular lymph nodes are suggestive of metastatic spread.
how are results from triple assessment used
At each stage of the triple assessment, the suspicion for malignancy is graded to create an overall risk index, as discussed below. The key here is to establish whether this is likely a benign lesion or whether the patient should go onto have more definitive biopsy and further intervention.
