Breast Examination

Question 1

Introduction

Answer 1

Introduce yourself
Patient ID

Undressing to waist
Inspect both breasts before placing the backs of my hands on the breast tissue to assess for any changes
I will also assess the glands in your armpits
My colleague will be present to act as my chaperone
Will this be ok?
If you are in any pain or would like me to stop, please let me know

Draw curtains
Offer gown or sheet to preserve dignity
Ask them to undress to the waist, step outside the room

Question 2

General inspection

Answer 2

Shape
Size
Symmetry

Ask patient to lift arms above their head
Ask patient to place hands on hips and push inwards
-contracts pec major to make deeper masses more visible
Ask patient to lie down at 45, place hand of side being examined under their head
-support head with pillow

Question 3

Close inspection

Answer 3

Examine side of concern first

Skin changes
-erythema = mastitis/abscess, fat necrosis, cancer
(+itch, scaling = Paget’s disease of breast, associated with insitu, invasive carcinoma
-puckering, peau d’orange (due to cutaneous lymphatic edema) = malignancy
-masses
-scars - lumpectomy/mastectomy
-discolouration

Nipple

• inversion/retraction - if not normal = breast cancer, breast abscess, mammary duct ectasia and mastitis
• discharge - often benign esp pregnant, breastfeeding
  
  • milky - galatorrhea => prolactinoma
  • purulent - mastitis/abscess
  • watery/bloody - want to rule out DCIS

Question 4

Palpation

Answer 4

Palmar of middle 3 fingers

• clockwise in each quadrant and nipple
• compare with other side
• observe for pain

Note

• size
• position
• consistency - hard, rubbery, fluctuant (hold mass between 2 fingers and push with other hand from top to feel any fluid bulging outward)
• mobility
• fixation to underlying skin/tissues

Can now ask patient to get dressed

Question 5

Axillary exam

Answer 5

Enlarged due to malignancy/secondary to infection

Patient to sit upright
take the weight of the patient’s arm => relax shoulder

Roll tissue between fingers and chest wall

• apex - central LN
• behind pec major - ant LN
• in front lat dorsi - post LN
• down humerus - lat LN

Supraclavicular, infraclavicular

Question 6

Other investigations

Answer 6

Mammography if 35+
USS if U35
FNA, core biopsy

Question 7

Opening script

Answer 7

Hello, I am An Nakamura, a 3rd year medical student
I’ve been asked to do a breast examination
I will have a look a both breasts and use the backs of my hands to examine the breast tissue.
This will require you to be undressed down to your waist and lie down at a 45 degree angle
As this is an intimate examination, a female chaperone will also be present
Do you have any questions for me?
Do I have your consent to perform this examination?
I’ll leave you to undress, please let me know when you’re ready

Do you have any pain in your arms?