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Breast Examination

Points from history:

  • PC: lump, skin change, pain, discharge, nipple inversion, deformity. Cyclical symptoms. If cancer suspected: symptoms of metastasis.
  • Risk factors (i.e. oestrogen exposure + radiation). Pregnant/breastfeeding.
  • PMH / FH of breast disease. Significant co-morbidities affecting surgery.
  • DH incl. Oral contraceptive pill. Smoking.
  • Don’t forget Ideas, Concerns, Expectations.

Examination

Intro Wash hands, Introduce yourself + your CHAPERONE, Check their name/DOB, Explain examination, Consent
Set the scene Privacy, Exposure = top + bra off; begin standing opposite the patient, then later get her(/him) to lie down horizontal for palpation
General Observation Pregnant/breastfeeding, systemically unwell, signs of metastasis
Inspect

 Skin:

  • Tethered/dimples
  • Discoloured,red, oedema (peau d’orange)

Nipples:

  • Inverted (often normal)
  • Discharge

Shape:

  • Asymmetry (often normal),
  • Lumps

(1) Arms by the side;

(2) Pressed into hips;

(3) Raising them gradually in an arc to right above their head

(Mirroring these movements makes her look/feel less stupid & gives you something to do other than gawk)

(You may need to lift up the more pendulous breast to have a peek underneath.)

Hands on hips contracts the pec muscles, revealing hidden asymmetry (e.g. cancer tethered to muscles)
Palpate Supine, arms relaxed above head, ask if any tender areas

Use a systematic method of not missing any area -e.g. circles/lines

But easiest is ‘The 7 Quadrants’:

  • Upper-inner
  • Lower-inner
  • Lower-outer
  • Upper-outer [clavicle is superior border]
  • Behind nipple
  • Axillary tail
  • Lymph nodes (axillary & supraclavicular)

Rolling the breast tissue in small circles under your middle three fingers should be enough to feel a lump.

For the axilla: take the weight of her arm yourself and bring it down nearer her side.
If a lump is found it should be palpated like any other – e.g. size, tenderness, texture, tethering, consistencyIf nipple discharge has been observed, you may be able to express some for cytology.

If cancer is suspected you should also examine the liver, lungs and spine for metastases.

Ix

FNAC/core biopsy, mammography +/or USS (i.e. ‘triple assessment’). (Rarely MRI). Later (if cancer): staging and hormone status (ER&PR)

Differential Diagnosis:

Lumpy: Cancer, cysts, fibroadenoma, fibrocystic disease, abscess, fat necrosis, galactocoele, ectopic breast tissue, non-breast tissue pathology.

Discharges: duct ectasia & mastitis, duct papilloma.