Breast examination

Introduction

• Wash hands
• Introduce self
• Ask Patient’s name, DOB and what they like to be called
• Explain examination and obtain consent
• Get a chaperone
• Expose and position patient (sitting first, then lying at 30˚)

General inspection

• Patient: age, well/unwell, cachexia

Look with patient sitting over edge of bed

• Look for
  • Asymmetry
  • Local swelling
  • Skin changes (erythema, dimpling, peau d’orange, scars)
  • Nipple changes (Paget’s disease of the breast, inversion)
• Look in four positions
  • Arms relaxed
  • 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

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

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
• Ask the patient to gently massage each nipple to attempt to express any discharge (yellow/green = infection; bloody = malignancy)

Lymph nodes

Ask patient to sit over the side of the bed again to examine the axillary lymph nodes.

To complete

• 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

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1. Breast exam OSCE station
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