Breast OSCE Exam

Question 1

What are the first 3 things you should do in a breast exam?

Answer 1

Wash hands
Introduce yourself
Confirm patient details - Name / DOB

Question 2

Give an example of how you’d explain the examination to a patient.

Answer 2

Today I’ve been asked to perform a breast examination, do you understand what this will involve?”

“The examination will involve me first inspecting the breasts, then placing a hand on the breasts to assess the breast tissue. Finally I will examine the glands of your neck and armpit.”

Question 3

How would you explain the need for a chaperone?

Answer 3

“One of the female ward staff members will be present throughout the examination, acting as a chaperone, is this ok?”

Question 4

What 3 questions might you ask to check the patient’s understanding?

Answer 4

• Does everything I’ve said make sense?
• Do you feel you understand what the examination will involve?
• Do you have any questions?

Question 5

How would you gain consent for a breast examination?

Answer 5

“Are you happy for me to carry out the breast examination?”

Question 6

How would you like to assess the patient?

Answer 6

• Ask pt to undress down to the waist behind the curtain (provide blanket to cover).

Question 7

If the pt has presented due to concerns about a lump, what should you ask about?

Answer 7

Ask the pt about the location of the lump.

Question 8

On general inspection, how would you like to position the patient?

Answer 8

Ask pt to sit upright, ideally on the side of the bed.

Ask pt to uncover breasts at this point.

Question 9

What should you look for on general inspection?

Answer 9

Any obvious masses, scars or asymmetry

Question 10

What are the 3 positions you’d like the patient to hold on close inspection?

Answer 10

• Arms by side
• Hands on hips
• Arms above head

Question 11

What 3 initial features would you look for on close inspection?

Answer 11

Scars: small scars (lumpectomy) / large diagonal scars (mastectomy)

Asymmetry: healthy breasts are often asymmetrical

Masses: note the size & position. Look for overlying skin changes.

Question 12

During ‘arms by side’ inspection, what 3 skin changes would you look for?

Answer 12

• Erythema: Infection / superficial malignancy
• Puckering: may indicate an underlying malignant mass
• Peau d’orange: cutaneous oedema - inflammatory breast cancer

Question 13

During ‘arms by side inspection’, what 3 nipple changes would you look for?

Answer 13

Retraction: congenital / underlying tumour / ductal ectasia

Discharge: may indicate infection or malignancy

Scale: may indicate eczema or Paget’s disease

Question 14

After ‘arms by side’ inspection, what should you do?

Answer 14

‘Hands on hips’ inspection.

- Repeat inspection (scars / asymmetry / masses / skin changes / nipple changes)

Question 15

During the ‘hands on hips’ inspection, a mass is noticed. What should you check if this is the case?

Answer 15

Observe to see if the mass moves with the pectoralis muscle.
This is known as ‘tethering’ and suggests invasive malignancy.

Question 16

How should you ask the pt to position themselves for the ‘Arms above head’ inspection?

Answer 16

Ask pt to place both hands behind their head.

Question 17

What should an ‘arms above head’ inspection involve?

Answer 17

Inspect the breast tissue for any evidence of:

• masses
• asymmetry
• dimpling / puckering

Question 18

Why should you ask a pt to lean forwards, keeping their hands behind their head?

Answer 18

This position will exacerbate any skin dimpling / puckering which may relate to an underlying mass.

Repeat inspection of the breast tissue, as above.

Question 19

What 3 areas require palpation?

Answer 19

• Breast
• Axillary tail
• Nipple

Question 20

Describe how you would palpate the breast.

Answer 20

Examine the “normal” asymptomatic breast first. Ensure to warm your hands before touching the patient.

Position the patient laid on the bed at a 45 degree angle.

Ask the patient to place their hand on the side being examined behind their head.

Use the flat of your fingers to compress the breast tissue against the chest wall, feeling for any masses.

Use a systematic approach to ensure all areas of the breast are examined:

Clock face method – examine each “hour” of the breast
Spiral method – start at the nipple and work outwards in a concentric circular motion

If a mass is detected, ensure you complete a thorough examination of the remaining breast tissue before examining the mass further.

Question 21

Describe how you would palpate the axillary tail of breast tissue

Answer 21

• Breast tissue often extends into the axilla & is known as the ‘axillary tail’.
• Majority of breast cancers develop in the upper outer quadrant, so it’s essential this area is examined thoroughly.

Question 22

Describe how you would investigate nipple discharge.

Answer 22

If pt reports having nipple discharge, ask them to squeeze the nipple to demonstrate this.

Yellow / green discharge: suggestive of infection

Bloody discharge: more suspicious of malignancy eg. papilloma.

Repeat palpation on the other breast, asking the patient to place their alternate hand behind their head.

Question 23

What are the 6 key features you should look for when examining a breast lump?

Answer 23

• Position
• Size & shape
• Consistency
• Overlying skin changes
• Mobility
• Fluctuance

Question 24

What 3 questions should you consider regarding the position of a lump?

Answer 24

• Which quadrant of the breast is the mass located within?
• Using the clock face metaphor, what ‘hour’ on the clock is the mass located at?
• How far away from the nipple is the mass located?

Question 25

What 2 questions should you consider regarding the size & shape of a lump?

Answer 25

• What are the approximate dimensions of the mass?

- What shape is the mass? eg. spherical, elongated, irregular

Question 26

What should you be looking for with regards to the consistency of the mass on palpation?

Answer 26

Smooth?
Firm?
Stony?
Rubbery?

Question 27

What skin changes should you look for?

Answer 27

Are there any changes to the skin surrounding / overlying the mass? eg. erythema / puckering.

Question 28

What would you consider when looking at the mobility of a mass?

Answer 28

• Does it move freely?
• Does it move with the overlying skin?
• Does it move with pectoral contraction?

Question 29

How would you assess the fluctuant of a mass?

Answer 29

Hold the mass by its sides, then apply pressure with another finger to the centre of the mass.

if the mass is fluid filled (eg. cyst), then you should feel the sides bulging outwards.

Question 30

What are the 5 steps to examining the axilla?

Answer 30

1. Have the patient sit on the edge of the bed facing you.
2. Support the patient’s arm on the side being examined with your forearm.
3. If you’re examining the right axilla, use your right arm to support the patient’s (vice versa for left).
4. Palpate the axilla with your free hand, ensuring to cover all areas of the axilla:
   Medial / lateral / anterior / posterior walls
   Apex of the axilla
5. Note any lymphadenopathy – malignancy / infection

Question 31

When performing a general lymph node examination, which other lymph nodes should you examine?

Answer 31

• Cervical
• Supraclavicular
• Infraclavicular
• Parasternal

Question 32

What 5 steps should you take to complete the examination?

Answer 32

1. Thank patient
2. Cover the pt up with a blanket / sheet
3. Leave the room and allow them time to re-dress
4. Wash hands
5. Summarise findings

Question 33

What further assessments / investigations might you suggest?

Answer 33

• Ultrasound
• Mammography
• Biopsy (fine needle aspiration / core biopsy) to determine histology.