Breast Examination Flashcards
How do you introduce yourself for a breast examination
- Wash hands while you’re talking to the patient
- Introduce yourself
- Confirm the patient’s identity
- Explain the examination
o “I’ve been asked to examine the breasts, have you ever had this done before?”
o “What this examination is going to involve is me inspecting the breasts, as well as placing a
hand on the breasts to assess the tissue. Finally I will examine some of the glands of your
neck and armpit.” - Explain the need for a chaperone
o “The examiner will be present throughout the examination to act as a chaperone, is this okay with you?” - Check understanding
o “Does everything I’ve said make sense?” o “Do you have any questions?” - Gain consent
o “Are you okay for me to proceed?” - Ask patient to undress from the waist up including their bra, provide a blanket to cover
- If the patient has presented due to concerns about a lump, ask the patient about the location of
the lump
How do you do a close examination of the breast
Close Inspection
- Arms by side – position the patient with their hands on their thighs relaxed
o Scars – small scars (lumpectomy) / large diagonal scars (mastectomy) o Asymmetry – healthy breasts are often asymmetrical
o Masses – not the size and position, look for overlying skin changes
o Skin changes
- Erythema – healthy breast
- Puckering – may indicate an underlying malignant mass
- Peau d’orange – cutaneous oedema; inflammatory breast cancer
o Nipple changes
- Retraction – congenital / underlying tumour / ductal ectasia
- Discharge – may indicate infection or malignancy
- Rash / scale – may indicate eczema or Paget’s disease
- Hands on hips – ask patient to place hands on their hips and push inwards (to tense pectoralis major)
o Repeat inspection
o Observe for masses again: if a mass is noted, observe to see if the mass moves with the
pectoralis muscle (=tethering; suggestive of invasive malignancy) - Arms above head – ask patient to place both hands behind their head
o Inspect the breast tissue for evidence of: - Masses
- Asymmetry
- Dimpling/puckering
- Same position, leaning forwards
o This will exacerbate any skin dimpling/puckering which may relate to an underlying mass
How do you examine the breast
- Breast
o Examine the asymptomatic breast first o Position the patient - Laid on the bed at a 45° angle
- Ask patient to place their hand on the side being examined behind their head o Use a systematic approach to ensure all areas of the breast are examined
- Use the flat of your fingers to compress the breast tissue against the chest wall, feeling for any masses
o If a mass is detected, ensure you complete a thorough examination of the remaining breast tissue before examining the mass further
How do you examine the nipple
o If the patient reports having nipple discharge, ask them to squeeze their nipple to
demonstrate this
- Yellow/green – infection, duct ectasia
- Bloody – malignancy, papilloma
How do you examine the axilla
o Have the patient sit on the edge of the bed facing you
o Support the patient’s arm on the side being examined with your forearm
o If you’re examining the right axilla, use your right arm to support the patient’s arm and vice
versa
o Palpate the axilla with your free hand, ensuring to cover all areas:
- Medial / lateral / anterior / posterior walls
- Apex of the axilla
o Note any lymphadenopathy
What other lymph nodes do you examine
o Cervical
o Supraclavicular
o Infraclavicular
o Parasternal
What examinations would you perform afterwards
e.g.
ultrasound (age <35yo) or mammography (age >35yo), FNA/CB
How would you examine a breast lump
- Position
o Quadrant of the breast
o Clock face metaphor
o How far away from the nipple - Size
o Approximate dimensions – e.g. 2cm ́ 3cm - Shape
o Round, elongated, irregular - Consistency
o Smooth, firm, stony, rubbery - Overlying skin changes
o Erythema, puckering, peau d’orange - Mobility
o Does it move freely?
o Does it move with overlying skin?
o Does it move with pectoral contraction? - Fluctuance
o Hold the mass by both sides and apply pressure with another finger to the centre of the mass o If the mass is fluid-filled (e.g. cyst), then you should feel the sides bulging outwards
What are mammary glands
- These are modified sweat glands that are specialised to secrete milk following pregnancy
Where anatomically are the breasts
The breasts overlie the pectoral muscle and extend from the second to the sixth ribs and from the sternum to the axilla.
How many lobes does a mammary gland contain
- they contain 15-20 lobes
What does each lobe contain
Each lobe contains alveolar glands and an alveola duct that leads to a lactiferous duct which in turn leads to the nipple and opens outside
What helps support the breasts weight
Suspensory ligaments extend inwards from the dermis of the breast to the fascia helping to support the breasts weight.
Where is the nipple located
The nipple is located at about the level of the fourth Intercostal space. A circular area of pigmented skin called the areola surrounds each nipple.
What is the axillary tail
- This is when the breast tissue extends into the axilla
