BREAST EXAMINATION Flashcards
Before actually starting the examination of a woman’s breast, what must you do?
Explain examination
Get a chaperone
Check understanding
Gain consent to continue
How should you have the patient positioned for the inspection part of a breast examination?
Sat upright on the side of the bed with arms by their side
What must you look for on general inspection of a patient for whom you are performing a breast examination?
Masses - size and position
Scars (eg lumpectomy, mastectomy)
Asymmetry - remember that healthy breast are often asymmetrical
Obvious skin changes
Obvious nipple changes
What skin changes might you see on closer examination of someone’s breast in a breast exam?
Erythema
Puckering
Peau d’orange
What might erythema seen on close inspection of a breast signify?
Infection
Superficial malingnancy
What might puckering of the skin seen on close inspection of a breast signify?
Underlying malignant mass
What might peau d’orange seen on close inspection of a breast signify?
It is cutaneous oedema and may signify inflammatory breast cancer
What nipple changes might you see on closer examination of someone’s breast in a breast exam?
Retraction
Discharge - either pus or blood
Scale
What might nipple retraction seen on close inspection of a breast signify?
Congenital anomaly
Underlying tumour
Ductal atresia
What might nipple discharge seen on close inspection of a breast signify?
Infection
Malignancy
What might scaling of the nipple seen on close inspection of a breast signify?
Eczema
Paget’s disease - can be associated with malignancy
Having more closely inspected a breast as part of a breast exam with the patient’s arms by her side and noted any skin or nipple changes, masses, scars or asymmetry, what must you then do?
Ask the patient to place their hands on their hips and push inwards (to tense pec major)
Then repeat inspection
What are you specifically looking for in terms of masses when you inspect a patient’s breasts with them tensing pec major?
Tethering - whether it moves with pec muscle
What is the significance of tethering of a mass, seen on inspection of a breast during tensing of pec major muscle?
Suggest invasive malignancy into the underlying tissue
Having inspected a patient’s breast with her hands on her hips, what must you then do as part of a breast exam?
Get her to raise her hands above her head.
What are you looking during inspection of a breast with the patient’s hands above her head?
Masses
Asymmetry
Dimpling
Puckering
How might you be able to exacerbate any skin dimpling or puckering during examination of a breast with the patient’s hands above her head?
Get her to lean forward
Having fully inspected the patient you then palpate the breast. How would you position the patient for this part of the examination?
Laid back at 45˚ with the arm on the side being examined behind her head.
What part of your hand would you use when palpating the breast as part of the breast exam?
The flat of your fingers
What are the two ways of systematically palpating the breast during a breast examination?
Clock face method - examine each “hour” of the breast
Spiral method - start at the nipple and work outwards in a concentric circular motion
Make sure that you also palpate the axillary tail of the breast - extending into the axilla slightly (majority of breast cancers develop in the upper outer quadrant)
What should you do if you palpate a mass in a breast examination?
Make sure you complete palpation of the rest of the breast before returning to the mass.
Note:
Position
Size and shape (spherical / elongated / irregular)
Consistency
Overlying skin changes
Mobility
Fluctuance
You have found a lump as part of palpation of a breast. What must you note about its position?
Which quadrant / “hour” (using clock face metaphor)
How far away from nipple it is
You have found a lump as part of palpation of a breast. What might you note about its consistency?
Smooth
Firm
Stony
Rubbery
Spongy
You have found a lump as part of palpation of a breast. What might you note about its mobility?
Does it move freely?
Does it move with overlying skin?
Does it move with pectoral contraction?
You have found a lump as part of palpation of a breast. How would assess the fluctuance of the mass and what might this indicate?
Hold the mass by its side then apply pressure with another finger to the centre of the mass.
If the mass is fluid filled (cyst) then you should feel the sides bulging outwards
If the patient has reported that she has noticed discharge, what must you do as part of the breast examination?
Ask the patient to squeeze the nipple to demonstrate this.
What might you notice about discharge from a nipple during a breast examination?
Yellow / Green / Milk - all suggestive of infection
Bloody - more suspicious of malignancy eg papilloma
Having palpated the breast as part of a breast exam, what must you then do?
Palpate each axilla
What are the areas of the axilla you must palpate as part of a breast examination?
Medial / lateral / anterior / posterior walls
Apex of the axilla (remember that this is really quite deep)
What are you looking for during palpation of the axilla as part of a breast exam? What would you comment on?
Lymphadenopathy - sign of malignancy or infection
Comment on:
Size
Consistency
Fixation
You have palpated the axillary lymph nodes as part of a breast examination? What other lymph nodes would you assess?
Cervical
Supraclavicular
Infraclavicular
Parasternal
Having finished the examination of the breast, what further assessments and investigations might you suggest?
Ultrasound
Mammography
Biopsy - fine needle aspiration or core biopsy
