Breast Examination Flashcards
What are the stages of this examination?
- Introduction
- General inspection
- Inspection of the breast
- Palpation of the breast
- Assess for lymphadenopathy
- Offer further investigations as appropriate
- Conclusion
Why is a chaperone essential?
Remember a chaperone is essential in an intimate examination. Functions of a chaperone include:
* reassure the patient
* protect the patient’s dignity and confidentiality
* offer emotional support
* facilitate communication
* safeguard patient
* safeguard doctor
* protect doctor from physical attack
What should be covered in the Introduction?
Introduction
Perform effective hand hygiene
Introduce self
Confirm patient’s name and date of birth
Ask patient if in any discomfort, noticed any lump or nipple discharge
Explain the procedure to the patient and seek permission to examine
Obtain a chaperone
Position patient seated with chest adequately exposed (ask patient to undress from
waist up)
Ensure that you explanation does not include medical jargon and is adequate to explain what you will be going on to do. If this is not done adequately the patient cannot give informed permission to proceed
What should be covered in the General inspection and palpation of the arms?
General inspection and palpation of the arms
Look for any signs of discomfort or cachexia
Inspect the hands and arms for signs of lymphoedema
Take a step back and observe the patient generally for any sign that they are in discomfort or pain. Look to see if there is any evidence of cachexia (weight loss and deterioration of physical condition) which raises the possibility of advanced cancer.
Inspect the hands and arms for any signs of lymphoedema. Lymphoedema is the accumulation of lymph fluid within the soft tissues. This causes swelling, tightness of the skin, thickening and dryness of the skin and jewellery e.g. rings may become tight. Clinically, the skin is firm and does not pit easily. Lymphoedema can be secondary to previous surgery or radiotherapy on axillary lymph nodes. It is also important to remember that other conditions can cause lymphoedema, including primary lymphoedema resulting from congenital insufficiency of the lymphatic system.
What should be covered in the Inspection of the breast?
Inspection of the breast
Inspect chest wall for scarring including scarring in the axillae
Inspect both breasts with patient seated with arms at sides, hands pressed into
hips and arms raised in air. Note size, shape, contour, colouration, venous pattern,
skin dimpling, symmetry and nipple inversion
Inspect underside of each breast
Inspect the chest wall and breasts for scarring. It may be necessary to lift the breast to inspect underside for scarring. Scars may be large or may be small and difficult to see for example from a lumpectomy. Scarring may also be around the areola (darker area of skin around the nipple). It is important to also look for scarring in the axillae.
Both breasts should be inspected with the patient seated. Initial inspection should take place with the patient relaxed with arms by their sides. The patient should then be instructed to place both hands on their hips and press firmly; this contracts pectoralis major and highlights any lesions that may be tethered to the underlying muscles. Then ask the patient to raise hands into the air, which again may highlight any lumps.
In each position, the breast should be inspected noting any obvious differences in the size between the breasts. Note that some degree of asymmetry can be normal, however. Differences in the shape and contour of the breasts may indicate an underlying lump.
The skin on the breasts should be inspected and any changes in colour noted. Breast lumps which present late may already show signs of fungating or ulcerating. Venous markings over the breast should also be noted - these may become more prominent in pregnancy and breast feeding.
Skin dimpling or peau d’orange (puckering of the skin so called as looks like orange skin) can be a sign of an underlying lump which may be tethered to the skin. Any rashes or dry skin should be noted in particular around the nipple area as this can be a sign of Paget’s disease of the breast.
Nipples should be inspected to see if there is any inversion and if so, whether this is uni- or bilateral. It is worth noting that nipple inversion can be a normal variant so asking about a change in the nipple to become inverted is more useful. Note if there is a discharge from the nipple and its colour e.g. white, green or blood stained.
Inspect the underside of each breast. Ask the patient for permission to gently lift each breast. If a patient has large breasts it may be more appropriate to inspect the underside of each breast when they are lying down.
What should be covered in the Palpation of breasts and lymph nodes?
Palpation of breasts and lymph nodes;
Ensure patient’s chest is adequately exposed for breast. examination.
Ask the patient to lie on examination couch with their head on a pillow
Ask patient to point, if relevant, to the site of pain or the lump and place
their hands behind their head
Examine the normal breast first using a one-handed technique in a logical
and structured manner
Palpate in turn: breast, areola, nipple, axillary tail, axilla and lymph nodes
Repeat on other side
N.B. The aim of breast palpation is to be systematic, so that the entire breast is examined thoroughly. There are a number of different techniques which can be used to achieve this. One approach is outlined below, but others are equally valid clinically.
The patient should be lying comfortably on the examination couch with a pillow under their head. Ask the patient to point to any areas that are painful, and to highlight any lumps if they have detected any.
Begin palpation of the normal breast first, ensuring that you start palpation away from any area of pain. It may be necessary to explain to the patient that you will need to palpate the painful areas in order to gain valuable information about any lumps present. It is normal to examine the breast without gloves unless a fungating or ulcerated area has been noted.
Ask the patient to raise their hands and place them behind their head. Palpation of the breast tissue should be performed in a logical and structured way. The breasts can be visualised as four quadrants and the nipple area.
Palpation should be done using the palmar surface of the 2nd, 3rd and 4th fingers using small circular motions. View the breast as a clock face. Examine each ‘hour of the clock’ from the outside towards the nipple, including under the nipple as illustrated below.
It is important to palpate the breast tissue deep to the nipple as a significant number of lumps occur in this area. If you were to detect a lump, you should then assess whether moving this lump accentuates or initiates nipple inversion.
Examine all the breast tissue. A one-handed technique should be adopted.
The nipple should be examined by holding it between your index finger and thumb. If the nipple is inverted you should press gently on each side of the nipple to see if it everts. If the patient complains of a nipple discharge, it is important to try to elicit this by gentle pressure around the areola. If discharge is present this should be sent off to the microbiology and cytology labs for analysis.
What should be covered in Assessing for lymphadenopathy?
Assess for lymphadenopathy
Palpate for axillary lymphadenopathy in a logical sequence
Palpate for supraclavicular lymphadenopathy in a logical
sequence
Palpate the left axilla with right hand and the right axilla with left hand. Palpate the anterior, posterior, lateral and medial regions in turn with the palmar surface, support the weight of the patients arm with your non-examining hand to relax the axillary muscles. Fingers of the examining hand should be held curved and pressed hard into the apex of the axilla. Note size, site and mobility of any nodes.
What should be covered in further investigations?
If a mass was to be present offer further investigations.
If a lump is detected during a breast exam, further investigations should be offered as appropriate. Ultrasound, Mammography or MRI can be used to evaluate the breast tissue. Fine needle aspiration, core biopsy or open surgical biopsy can be used for a pathological diagnosis. The combination of clinical assessment, imaging of breast tissue and pathological diagnosis is known as a triple assessment. Complete your guided study for further details.
What should be done if a lump is found?
If the patient has identified a breast lump but it cannot be found on examination, you should ask the patient to demonstrate the lump for you.
Any masses found should be assessed for size and any recent change in size noted.
The consistency should also be noted for example whether rocky ‘craggy’ and hard (typical of carcinomas) or firm and rubbery (typical of fibroadenomas). Cysts are often smooth mobile or spongy, they can increase and decrease in size, or even disappear prior to assessment.
Whether or not a lump is tender should be noted but remember that a breast lump may become tender if they have been examined a lot by yourself and the patient. The skin may also become red if repeatedly examined.
The mobility of any lump should also be assessed. This can be done initially by assessing how much the lump can be moved in 2 directions at right angles to each other with the patient relaxed. Then hold the lump between your thumb and forefinger and ask the patient to contract and relax the pectoral muscles alternately by pushing into their hips. As the pectoral muscle contracts, note whether the lump moves with it. The mobility of the lump should also be re-assessed. If the lump moves with muscular contraction / mobility of the lump is restricted with muscle contraction, this indicates it is more likely to be fixed or tethered to the underlying muscle. This may suggest malignancy. Tethered and fixed lumps may cause some skin dimpling or peau d’orange.
What is Skin dimpling/Peau d’orange a sign of?
Tethered and fixed lumps may cause some skin dimpling or peau d’orange.
If nipple discharge is present what should be done?
It is important to try to elicit this by gentle pressure around the areola. If discharge is present this should be sent off to the microbiology and cytology labs for analysis.
Why may a patient have an inverted nipple?
Typically, an inverted nipple associated with breast cancer happens when a tumor attacks a milk duct behind the nipple, causing the skin to pull inward, or when cancer cells affect the nipple itself. This symptom usually comes on suddenly and may accompany other breast changes
What should be covered in the Conclusion?
Conclusion
Cover the patient as soon as examination is complete
Thank patient and perform effective hand hygiene
Summarise and present findings orally
As soon as the examination is complete cover the patient to maintain their dignity. Your patient should be exposed for the minimal amount of time. Look away and allow time for the patient to dress. Ensure that their privacy is maintained at all times. Due to the intimate nature of this examination it is important to provide adequate explanation throughout.
After thanking your patient and washing your hands, summarise and present your findings orally to your tutor.
Remember SBAR when summarising your findings.
