Breast Examination

Page 1

Before you start

Ensure patient needs a breast examination

Be able to tell patient what you intend to do & why

Be able to discuss the risks and benefits of the intended procedure

Understand how to gain informed consent

Introduction

1. Wash hands

2. Introduce yourself

"Hi, my name is Aleda and I'm a 3rd year medical student"

3. Confirm patient details

Name, DOB, NHS no.

4. Explain the procedure

"I've been asked to do a breast examination today, do you understand what this will involve?"

"It will involve me first inspecting the breasts then placing a hand on the breasts to assess the breast tissue. I will also be examining the glands of your neck and armpit."

5. Explain need for a chaperone

"One of my female colleagues will be present throughout acting as a chaperone, is this OK?"

6. Assess understanding

"Do you understand everything I've said to you?"

7. Gain consent

"Are you OK to go ahead with this examination?"

Page 2

Pre - Breast Examination

1. Wash hands

2. Ask patient to undress down to the waist behind the curtain

Provide blanket to cover

3. Ask about location of lump

4. Get the patient to stand up/sit up right on edge of bed initially

5. Palpate axilla while supporting patient's arm with your free hand

Medial / lateral / post / ant walls

Apex

Note any lymphadenopathy = Malignancy / Infection

6. Palpate other lymph nodes

Cervical

Supraclavicular

Infraclavicular

Parasternal

General examination

1. Ask to uncover breasts at this point

2. Inspect breasts

Note any

Masses

Scars

Asymmetry

Swelling

Skin/nipple changes

Close examination

1. Inspect breasts with patients arms on her thighs relaxed

Scars

Small scars = Lumpectomy

Large diagonal scars = Mastectomy

Asymmetry

Healthy breasts are often asymmetrical

Masses

Note size & position

Skin changes

Erythema = Infection / Superficial malignancy

Puckering = Underlying malignancy

Peau d'orange = Inflammatory breast cancer

Nipple changes

Retraction = Congenital / Malignancy / Ductal Ectasia

Discharge = Infection / Malignancy

Scale = Eczema / Paget's

2. Repeat inspection with hands placed firmly on hips

3. Ask patient to put both hands behind their head & repeat inspection

4. Ask patient to lean forward with hands still behind head & repeat inspection

This position will exacerbate dimpling/puckering

Palpation

1. Position patient at 45 degrees on bed with their hand behind their head

EXAMINE ASYMPTOMATIC BREAST FIRST

2. Use the flat of your fingers to compress the breast tissue against the chest wall

Use a systematic approach to examine all 4 quadrants for masses (e.g. clock-face method, spiral method)

If a mass if felt, complete the breast exam before returning to examine the mass further.

3. Palpate the axillary tail (breast tissue extending into the axilla)

4. Ask patient to squeeze the nipple if they report nipple discharge

Yellow/green discharge = Infection

Bloody = Malignancy

5. Repeat on other side

6. Examine any breast lumps

Note

Position

Which quadrant of the breast is the lump located in?

How far away from the nipple?

Size & shape

What are the approx dimensions?

What shape is the mass?

Consistency

Smooth/firm/stony/rubbery?

Overlying skin changes? (e.g. erythema / puckering)

Mobility

Does it move freely?

Does it move with the overlying skin?

Does it move with pectoral contraction?

Fluctuance = Assess by holding mass by it's sides and applying pressure with another finger to the center of the mass

Is the mass fluid filled? (Sides will bulge outward)

7. Cover patient & leave the room so that they can re-dress

Page 3

Completing the examination

Thank patient

Wash hands

Summarise findings

Lymphadenopathy?

Skin/nipple changes?

Any masses in the breast? Character of masses?

Suggest further investigations

USS

Mammography

Biopsy (Fine needle aspiration / Core biopsy)

Palpation of the spine

Auscultating the chest

Palpating for the liver