Breast Exam Flashcards
How do you explain the breast exam?
- Today I’ve been asked to perform an examination of your breast tissue.
- The examination will involve me first inspecting the breasts
- then placing a hand on the breasts to assess the breast tissue.
- finally I will examine the glands of your neck and armpit
What is important to mention about chaperone?
- The examiner will act as a chaperone
- Would you like anybody else present?
- Are you happy for me to proceed?
How do you explain exposure to the patient?
- For this examination, you will need to undressed from the waist up including your undergarments.
- I will draw the curtain to give you some privacy, there is also a robe for you to cover yourself.
- Just call me when you are ready. Once you are ready, sit on the edge of the bed.
What do you mention in general inspection?
- she doesn’t seem to be in pain, but appears to be anxious
- on closer inspection, there is no abnormality apart from a slightly inverted left nipple
What do you look for on inspection?
• Facing the patient, note if there is any:
- Asymmetry (including shape and size of breasts).
- Local swelling or lumps (including visible lymphadenopathy).
- Skin changes (including erythema, rashes, scaling, puckering and peau d’orange).
- Nipple changes (including inversion, symmetry and discharge).
What are the 4 ways to hold your hands on a breast exam?
- Arms relaxed at the side
- Hands on hips
- Arms raised above the head
- Bending forwards
What is important to mention on inspection?
- Let the patient know what you’re doing before you do it
2. Indicate that you would like a light source to be present.
Why at the start of the inspection are the patient hand on their thighs?
relax the pectoral muscles
Why do you ask the patient to put the hands on their side?
pressing their hands firmly onto their hips in order to contract the pectoralis muscles and accentuate any puckering
What could puckering suggest?
may be due to infiltrative masses fixed to the underlying muscle
Why do you ask for their hands to be on their head with elbows out leaning forwards?
position exposes the whole breast, exaggerating any asymmetry
How do explain the different hand movements?
- Can you put your hands by your side?
- “If you could put your hands on your hips for me and press down the hips.”
- “And now, if you could put both of your hands behind your head, and push your elbow back, and lean forward for me”
What possible things could you see on inspection?
- Mastitis
- Eryhtema
- Scaling
- Puckering/dimpling
- Peau d’orange
- Nipple inversion
What is mastsis and how is it investigated?
- redness (erythema)
- tenderness
- fever
- postpartum
- ultrasound will indicate abscess or mastitis
What does erythema appear as?
superficial reddening of the skin due to local inflammation
What would erythema suggest?
often secondary to 1. infection 2. trauma 3. malignancy triggering cutaneous vasodilatation
What does scaling with pruritis and lichenification (hardening) of the nipple and/or areola suggest?
Paget’s disease of the breast
When is there Paget’s disease of the breast?
- ductal carcinoma in situ
2. invasive breast carcinoma
When does puckering or dimpling occur?
due to neoplastic invasion of the suspensory (Cooper’s) ligaments, which normally provide the breast tissue with structural integrity
What is the patho of the puckering?
malignant fibrosis and contraction of these ligaments pulls the overlying skin inwards
What is peau d’orange?
is breast oedema associated with an inflammatory cancer or infection
How does peau d’orange happen?
- obstruction of dermal lymphatics and extensive axillary involvement
- resulting in skin swelling between the hair follicles
- thus resulting in an ‘orange peel’ dimpled appearanc
What can accompany peau d’orange?
redness, tenderness and warmth may be apparent
When is nipple inversion normal?
e.g due to significant weight loss
When can nipple inversion suggest pathology?
recent onset and with other features
What pathologies can nipple inversion suggest?
- mammary duct ectasia
- mastitis
- breast carcinoma
What is the position of the patient in the breast exam?
- patient lying on the bed at 45 degrees
- put ipsilateral hand behind their head
Which breast do you examine first?
uncomplicated one
How do you explain the procedure>
- “If you could lie down for me now, I am going to examine the breast.”
- Any pain, lumps, any nipple discharge?
- “I am going to start with the normal breast first.” “If you could put your right/left hand behind your head for me.”
What do you ask them to do with their nipple?
‘I want to make sure there is no discharge from the nipple. If you could squeeze your nipple between your thumb and right index finger’
What would yellow/green discharge suggest?
infection
What would bloody discharge suggest?
malignancy (e.g. papilloma)
How do you palpate the breast?
- Use the flat of your fingers to palpate the breast in a circular motion starting at the nipple and moving outwards
- Even if a lump is identified, make sure you continue with the examination and thoroughly examine the entire breast
- Make sure you palpate the axillary tail
What is important to remember when palpating the breast?
- maintain the patient’s dignity and minimise exposure where necessary
- e.g when examining the left breast, cover the right breast with a blanket
What should persistent single duct discharge or blood-stained (macroscopic or microscopic) discharge be investigated to exclude?
- duct ectasia (green discharge)
- duct papilloma (yellow discharge)
- ductal carcinoma in situ (red, bloody discharge)
In the presence of mass what would blood discharge suggest?
invasive carcinoma
How do you describe a breast lump?
- site
- size and shape
- consistency
- mobility
- fluctuance
What do you comment on with site on the breast lump?
- Identify which breast quadrant the lump is in (e.g. upper outer)
- Using the clock-face metaphor identify what ‘time’ the lump is at
What do you comment on with size and shape of a breast lump?
- Approximate dimensions of the mass
2. Shape of the mass (e.g. spherical, irregular)
What do you comment on with consistency of a breast lump?
- Smooth
- Firm
- Rubbery
What do you comment on with mobility of a breast lump?
- Does the lump move freely?
- Does it move with the overlying skin?
- Does it move with pectoral contraction?
What do you comment on with fluctuance?
- Hold the mass by its sides and apply pressure on the centre of the mass with another finger
- If the mass is fluid-filled (e.g. cyst), you should feel the sides bulging outwards
What position is the patient in for palpitation of the axilla?
ask the patient to sit on the edge of the bed, facing you
How do you palpate the axilla?
• Support the weight of the patient’s arm on the side that you are examining
• Palpate ALL AREAS of the axilla:
• Check for any lymphadenopathy (may suggest
malignancy or infection)
What are the three checks for sites of metastases?
- Auscultate the lung bases
- Palpate the vertebral column to check for tenderness = Percussion
- Palpate and percuss for hepatomegaly – I will now flatten the bed, if you could lie flat so I can feel for the liver
Why do you auscultate lung bases?
look for pleural effusion
How do you close the exmaination?
- Thank you very much for letting me examining you, you can get dressed now
- Do you need any help?
- Turn around to show you are giving the patient privacy to get redressed.
- Remember to clean up the equipment from the station
How would you finish the assessment?
- Examination
- Imaging = <35 ultrasound, >35yo
mammogram - Tissue sampling = FNA for cystic, and core
biopsy for solid mass
