Clinical Assessment of the Breast Flashcards
What is triple assessment of the breast?
- Clinical assessment - history and examination
- Imaging - mammography; ultrasound
- Pathological assessment - histology (core biopsy); (very rarely now, cytology, FNAC)
General questions to ask in breast history?
- Patient details
- Family history of breast cancer
- Smoking history
- Prescribed medication
- Allergies
- Alcohol history
- History of breast disease
- Educational background
- Occupation
- Past medical history
- Past hospital admissions
- HIV status
Obstetric history in breast history?
- Age at first menarche
- Menstrual history : cycle, date of last period
- Contraceptive history
- Age of first pregnancy
- How many pregnancies
- History of breast feeding
- Age at menopause
- Use of hormone replacement
- HIV status
What should be noted in history of presenting complaint of breast disease?
- When it was first noticed
- What made them first notice
- Pain
- Associated symptoms
- What made them present to the clinic
- How long did they wait to come
- Why did they wait to come?
- patient delays or system delays - How have they been treating it? Traditional medicine?
Components of inspection?
- Correct positions
- Clinical signs: shape
- Clinical signs: skin
3 positions for clinical inspection?
- Erect: at rest
- Erect: arms elevated
- Erect: pectorals contracted
• Akimbo - waist squeeze
• Akimbo - hip press
• Prayer position
What does the prayer position show?
Skin dimpling may become apparent or be accentuated
Clinical signs with regards to the shape of the breast?
- Symmetry
- Contour
- Nipple position
Clinical signs with regards to skin on the breast?
- Dimpling
- Skin tethering
- Muscle tethering - Peau d’orange
- Erosion/ulceration/fungation
- Nipple/areola: retraction/distortion/ inversion/erosion/eczema/oedema
Skin dimpling?
sunken pitted area with an uneven texture
Skin tethering?
relative to skin, a lump is said to be tethered when it can be moved independently of the skin for a limited distance
Muscle tethering?
Mass has invaded the muscle so is now immobile
Peu d’orange?
hair follicles become buried in edema giving the skin an orange peel appearance
Palpation?
- Position patient
- flat on couch
- arms behind head
- flatten breast - Position yourself
- flat of middle three fingers, distal third, both hands - Superficial palpation
- stroking round clock - Deep palpation
- rotation - around clock
Palpation of the axilla?
- support elbow (fully, relax pecs)
- same part of hand as for breast
- fingertips to top of axilla
- stroke firmly down ribs
Describing a lump?
- Describing a lump in o’clock position
- size in two dimensions
- distance from nipple
- surface/contour: smooth, irregular etc
- texture: hard, soft, rubbery etc
- mobility/fixation
- tenderness
3 finger technique for Palpation?
- Palpate the breast using the distal part of palmar surface of the middle three fingers, not the finger tips
- Two hands should be used to support and palpate the breast.
- If a lump is found, use two hands to assess its characteristics
Tethered lesion?
- A tethered lesion is suggestive of locally advanced cancer and occurs when the fibrous strands that radiate between the pectoral fascia and the skin, through the breast tissue are
shortened. - These ‘ligaments’ are anchored to the skin so that shortening them puckers the skin and pulls it inwards, although the lesion is still mobile and can be moved independently of the skin.
- A fixed lesion may have spread into the skin itself so that the mass cannot be moved independently of the skin and implies more advanced local disease
- Alternatively it may have invaded the muscle and so is fixed to the muscle. Note: You must distinguish between
skin and muscle fixation.
Nipple discharge?
• During breast examination DO NOT routinely squeeze nipples in women who have no complaint of nipple discharge (and then only with specific consent):
History of nipple discharge?
- Investigate all women with new discharge >50yrs
- Investigate women under 50 with
- bloodstained discharge
- spontaneous uniduct discharge
- bilateral discharge sufficient to stain clothes - Examine and if normal (2/3 NORMAL WOMEN HAVE BILATERAL MULTIDUCT DISCHARGE) => reassure
Note: this physiological discharge may range from clear through
cream/yellow/green to almost black - Any abnormality on examination, proceed to triple assessment
