BREAST EXAMINATION

Question 1

Before actually starting the examination of a woman’s breast, what must you do?

Answer 1

Explain examination

Get a chaperone

Check understanding

Gain consent to continue

Question 2

How should you have the patient positioned for the inspection part of a breast examination?

Answer 2

Sat upright on the side of the bed with arms by their side

Question 3

What must you look for on general inspection of a patient for whom you are performing a breast examination?

Answer 3

Masses - size and position

Scars (eg lumpectomy, mastectomy)

Asymmetry - remember that healthy breast are often asymmetrical

Obvious skin changes

Obvious nipple changes

Question 4

What skin changes might you see on closer examination of someone’s breast in a breast exam?

Answer 4

Erythema

Puckering

Peau d’orange

Question 5

What might erythema seen on close inspection of a breast signify?

Answer 5

Infection

Superficial malingnancy

Question 6

What might puckering of the skin seen on close inspection of a breast signify?

Answer 6

Underlying malignant mass

Question 7

What might peau d’orange seen on close inspection of a breast signify?

Answer 7

It is cutaneous oedema and may signify inflammatory breast cancer

Question 8

What nipple changes might you see on closer examination of someone’s breast in a breast exam?

Answer 8

Retraction

Discharge - either pus or blood

Scale

Question 9

What might nipple retraction seen on close inspection of a breast signify?

Answer 9

Congenital anomaly

Underlying tumour

Ductal atresia

Question 10

What might nipple discharge seen on close inspection of a breast signify?

Answer 10

Infection

Malignancy

Question 11

What might scaling of the nipple seen on close inspection of a breast signify?

Answer 11

Eczema

Paget’s disease - can be associated with malignancy

Question 12

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?

Answer 12

Ask the patient to place their hands on their hips and push inwards (to tense pec major)

Then repeat inspection

Question 13

What are you specifically looking for in terms of masses when you inspect a patient’s breasts with them tensing pec major?

Answer 13

Tethering - whether it moves with pec muscle

Question 14

What is the significance of tethering of a mass, seen on inspection of a breast during tensing of pec major muscle?

Answer 14

Suggest invasive malignancy into the underlying tissue

Question 15

Having inspected a patient’s breast with her hands on her hips, what must you then do as part of a breast exam?

Answer 15

Get her to raise her hands above her head.

Question 16

What are you looking during inspection of a breast with the patient’s hands above her head?

Answer 16

Masses

Asymmetry

Dimpling

Puckering

Question 17

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?

Answer 17

Get her to lean forward

Question 18

Having fully inspected the patient you then palpate the breast. How would you position the patient for this part of the examination?

Answer 18

Laid back at 45˚ with the arm on the side being examined behind her head.

Question 19

What part of your hand would you use when palpating the breast as part of the breast exam?

Answer 19

The flat of your fingers

Question 20

What are the two ways of systematically palpating the breast during a breast examination?

Answer 20

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)

Question 21

What should you do if you palpate a mass in a breast examination?

Answer 21

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

Question 22

You have found a lump as part of palpation of a breast. What must you note about its position?

Answer 22

Which quadrant / “hour” (using clock face metaphor)

How far away from nipple it is

Question 23

You have found a lump as part of palpation of a breast. What might you note about its consistency?

Answer 23

Smooth

Firm

Stony

Rubbery

Spongy

Question 24

You have found a lump as part of palpation of a breast. What might you note about its mobility?

Answer 24

Does it move freely?

Does it move with overlying skin?

Does it move with pectoral contraction?

Question 25

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?

Answer 25

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

Question 26

If the patient has reported that she has noticed discharge, what must you do as part of the breast examination?

Answer 26

Ask the patient to squeeze the nipple to demonstrate this.

Question 27

What might you notice about discharge from a nipple during a breast examination?

Answer 27

Yellow / Green / Milk - all suggestive of infection

Bloody - more suspicious of malignancy eg papilloma

Question 28

Having palpated the breast as part of a breast exam, what must you then do?

Answer 28

Palpate each axilla

Question 29

What are the areas of the axilla you must palpate as part of a breast examination?

Answer 29

Medial / lateral / anterior / posterior walls

Apex of the axilla (remember that this is really quite deep)

Question 30

What are you looking for during palpation of the axilla as part of a breast exam? What would you comment on?

Answer 30

Lymphadenopathy - sign of malignancy or infection

Comment on:

Size

Consistency

Fixation

Question 31

You have palpated the axillary lymph nodes as part of a breast examination? What other lymph nodes would you assess?

Answer 31

Cervical

Supraclavicular

Infraclavicular

Parasternal

Question 32

Having finished the examination of the breast, what further assessments and investigations might you suggest?

Answer 32

Ultrasound

Mammography

Biopsy - fine needle aspiration or core biopsy