Breast exam

Question 1

Draping

Answer 1

Begin with sitting, must expose both breasts for inspection, gown open in front, can expose on one at a time for palpation.

Question 2

Inspection

Answer 2

Patient sitting upright, arms at sides (other positions: above head, at waist, leaning forward).
Inspect breasts for: size, symmetry, shape and contour (abnormal bulging, skin retraction), skin changes/superfiscual appearance - erythema, edema, abnormal vascularity)
Nipples - inspect for size, symmetry, shape (inversion, eversion), skin changes ( erythema, eczema, ulcerations, scaling), spontaneous secretion, supernumerary nipples (most commonly along milk line, in the axilla, below the breast)

Question 3

Palpation - 1

Answer 3

Lymph nodes

• ant and post cervicle
• above and below clavicles
• axillary - pectoral/anterior, subscapular/posterior, lateral, central axillary
• comment on: size, consistency, tenderness, mobility

Question 4

Palpation 2

Answer 4

Patient in supine, expose one breast at a time, start with asymptomatic breast.
Palpate from clavicle to inframmmary line, midsternum to midaxillary line.
Use pads of second, third and fourth fingers to make small circular motions - applying three levels of progressively deeper pressure.
Vertical strip method - vertical strips, moving from 2nd to 6th rib, then upwards, slightly overlapping, continue until sternum.

Question 5

Breast masses

Answer 5

Note:

• location (quadrant or clock + distance from nipple)
• size
• shape (round, regular/irregular)
• consistency (soft/firm)
• delineation (discrete vs blends into surrounding tissue)
• tenderness
• mobility

Question 6

Exam in males

Answer 6

distinguish between - enlargement consisting of soft fatty tissue (obesity) and firm, glandular tissue (gynecomastia)

Question 7

characteristics of carcinoma

Answer 7

Location: usually solitary, unilateral, (often upper, outer quadrant)
Size: variable
shape: irregular
consistency: firm or hard
Delineation: ill-defined
Tenderness: usually non-tender
Mobility: may be fixed to skin or underlying tissues
Menstrual changes: none

Question 8

Characteristics of fibroadenoma

Answer 8

Location: usually solitary
Size: 1-3 cm (possibly larger)
Shape: Round, disc-like or lobular
Consistency:firm and rubbery (may be soft)
Delineation: well-defined
tenderness: usually non-tender
Mobility: mobile
Menstrual changes: may change in size with  menstrual cycle

Question 9

Characteristics of fibrocystic condition:

Answer 9

Location: solitary or multiple, bilateral
size- variable - may increase in size or regress
shape: round
consistency: soft to firm, elastic, depends on tension of fluid in cyst
delineation: well defined
tenderness: often tender
mobility: mobile
Menstrual changes: increased tenderness pre-menstruation

Question 10

Breast history incl

Answer 10

• breast pain
• breast masses
• skin changes
• associated symptoms of malignancy
• Risk factors (major and minor)

Question 11

Breast pain

Answer 11

Characterize - cyclic bilateral mastalgia vs. non-cyclin focal pain
OPQRST (change over time)

Question 12

Breast Mass

Answer 12

Location, 4s (size, shape, symmetry, skin changes), mass size change with cycle, tenderness

Question 13

Nipple changes

Answer 13

Retraction, ulceration or scaling, discharge (colour, consistency, bilateral vs unilateral, spontaneous vs manual secretion, blood)
6 s - size, shape, symmetry, skin changes, secretions, supernumerary nipple

Question 14

Skin changes

Answer 14

colour, texture, dimpling, (peau d’orange)

Question 15

Associated symptoms

Answer 15

Fever, weight loss, CNS changes, bone pain/fractures, hemoptysis, dyspnea

Question 16

Major risk factors for breast cancer

Answer 16

• Female age > 50
• Family history of breast/ovarian cancer in 1st or 2nd degree relative (progressive prostate)
• Genetics (BRCA 1, 2)
• History of hyperplasia (atypical ductal hyperplasia)
• High dose radiation

Question 17

Minor risk factors for breast cancer

Answer 17

• Nulliparity
• Age > 30 at first pregnancy
• Manarche 55
• Hormone replacement therapy >5 years
• Obesity
• Excessive alcohol consumption
• History of breast biopsy
• (OCP?)

Question 18

Past med

Answer 18

history of radiation, biopsy, previous complaints, examinations, current place in menstrual cycle,
# of pregnancies, gestations past 32 weeks.
if children - nursing and for how long
Smoking

Question 19

When to do CBE

Answer 19

when woman has breast complaint. ideally 7-10 post-menses
- no evidence for self-exam, better just to be familiar - attention to new lumps, dimpling, nipple or skin changes, pain which is persistent and not related to menstrual cycle

Question 20

Mammography indications

Answer 20

not for under 40 - too dense, high false positive rate.
40-49 with risk factors and discussion with patient of risks and benefits
50-70 every 2-3 years
over 75 stop