Nipple changes (Paget’s disease of the breast, inversion)
Look in four positions
Hands rested on thighs
Hands actively pressed into hips (tenses pectorals)
Hands behind head leaning slightly forwards (to expose whole breast and accentuate dimpling)
Also lift the breast to look in the submammary fold
Feel with patient lying
Position patient lying at 30˚. When examining the right breast, the patient’s right hand should be behind their head, and vice versa for the left. Ask if there is any pain first and start by examining the normal side.
Examine using both hands, massaging the breast tissue using the whole of the palmar surface of your middle three fingers
Move your hands in step-wise increments around breast in a systematic manner, e.g. a spiral motion from outside in
Examine the axillary tail between your first two fingers and thumb
Describe any lump (SSSCCCTTT): Site, Size, Shape, Consistency, Contours, Colour, Tenderness, Temperature (Transillumination not required here)
Ask the patient to gently massage each nipple to attempt to express any discharge (yellow/green = infection; bloody = malignancy)
Ask patient to sit over the side of the bed again to examine the axillary lymph nodes.
Axillary lymph nodes
To examine the right,ask the patient to hold your right biceps while you support the weight of their right arm at the elbow with your right hand
Place your left arm over your right and place your left hand into their axilla
Now palpate the apical, lateral, medial, anterior and posterior lymph node groups by firmly pressing the soft tissues and rolling them over the underlying harder tissues
Repeat using opposite hands for the left side.
Supraclavicular lymph nodes
Feel with your fingertips pressed into the supraclavicular fossae from anteriorly
Thank patient and restore clothing
Summarise and suggest further investigations you would consider after a full history
Two week wait referral for triple assessment (examination + imaging + tissue sampling)
Imaging depends on age: ultrasound if <35 years; mammogram if >35 years
Tissue sampling depends on mass: fine needle aspiration if cystic; core biopsy if solid
Some viva questions
What are DCIS and LCIS?
What is Paget’s disease of the breast?
What are the benign differentials for a breast lump?