Introduction
- Wash hands (and don PPE if needed)
- Introduce yourself (name and role)
- Confirm patient’s name and DOB
- Explain what the examination involves - using patient friendly language
- Explain the need for a chaperone “One of the female ward staff members will be present throughout the examination, acting as a chaperone, would that be ok?”
- Check patient understanding and gain consent to continue
- Over a gown if able
- Ask if they have any pain before proceeding
- If a patient is concerned about a lump as for its location
General Inspection
Ask the patient to undress down to the waist to adequately expose their breasts
Clinical Signs
- Asymmetry
- Swelling
- Masses
- Skin changes
- Nipple changes
Nipple abnormalities
Nipple inversion is a normal finding in a significant proportion of women (e.g. congenital or weight-loss associated nipple inversion). However, if nipple inversion develops without a clear precipitant, the possibility of underlying pathology should be considered. Possible pathological causes of nipple inversion include breast cancer, Breast abscess, mammary duct ectasia and mastitis.
Nipple discharge is benign is most cases (e.g. Pregnancy, breast-feeding) however less commonly it can be associated with mastitis or underlying breast cancer (rare).
Skin changes
Scaling of the nipple and/or areola associated with erythema and pruritis are typical features of Paget’s disease of the breast (see the example image). Paget’s disease is associated with underlying in-situ or invasive carcinoma of the breast.
Erythema of the breast tissue has a wide range of causes including infection (e.g. mastitis or Breast abscess), trauma (e.g. fat necrosis) and underlying breast cancer.
Puckering of breast tissue is typically associated with invasion of the suspensory ligaments of the breast by an underlying malignancy that results in ligamentous contraction which draws the skin inwards.
Peau d’orange (dimpling of the skin resembling an orange peel) occurs due to cutaenous lymphatic oedema. The dimples represent tethering of the swollen skin to hair follicles and sweat glands. Peau d’orange is typically associated with inflammatory breast cancer.
Exaggerating manoeuvres
Repeat inspection in the following positions:
- Hands pushing into hips (to contract pec muscles) - if a visible mass moves it suggests tethering
- Arms above head and leaning forward - exaggerating asymmetry, skin dimpling or puckering
Palpation
Adjust the bed to 45 degrees and ask the patient to lie down
Only expose one breast at a time
- Begin palpation on the asymptomatic breast first and then repeat all steps on contralateral breast.
- Ask patient to place the hand on the side that’s being examined behind their head
- Use a systematic method of palpation to ensure all areas of the breast are examined
- Use the flats of your middle three fingers to compress the breast tissue against the chest wall, as you feel for any masses. If a mass is detected, assess the following characteristics:
- Location - which quadrant and how far away from the nipple
- Size & shape- approx dimensions & shape
- Consistency - smooth/firm/stony/rubbery
- Mobility - does it move freely/with overlying skin/muscle?
- Fluctuance - hold the mass by the sides and apply pressure to feel if sides bulge outwards indicating that it is fluid filled (cyst)
- Overlying skin changes
- Continue palpation towards the axilla
Lymph nodes
Ensure dignitiy and modest are maintained - dependant on gown given
Axilla
- Ensure the patient is lying down at 45
- Ask if the patient has any pain in shoulder before moving arm
- Inspect each axilla for evidence of scars, masses or skin changes
- Hold the patients arm in your hand and ask them to relax
- Palpation should be performed with the other hand
- Palpate from the lateral edge of the pec major muscle to the anterior edge of lats to the inner aspect of the arm
- Repeat for other arm
Other lymph nodes
Ask the patient to sit up
Palpate:
- Cervical
- Supraclavicular
- Infraclavicular
- Parasternal
To Complete the Exam
- Explain to the patient that the examination is now finished.
- Thank the patient for their time.
- Dispose of PPE appropriately and wash your hands.
- Summarise your findings.
Further Assessments and Investigations
- Mammography - usually over age of 35
- USS - used in patients under 35 due to increase density of breast tissue
- Biopsy - fine-needle aspiration or core biopsy may be considered if a breast lump needs further assessment