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

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)

Describing a lump

For any mass, note its characteristics

SSSCCCTTT: Size, Shape, Surface, Consistency, Contours, Colour, Temperature, Tenderness, ( Transillumination not required here)

Lymph nodes

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

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

What are DCIS and LCIS?

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What is Paget’s disease of the breast?

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What are the benign differentials for a breast lump?

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

Interpretation management

Covered in OSCE Stations

Try it out!

1. Breast exam OSCE station
2. Breast cancer exam
3. Find more stations here