Breast Examination

TO START

W2I2P4E C

  • Wash your hands

  • Wear appropriate PPE

  • Introduce yourself and check patient’s Identity

  • Permission: Clearly explain the procedure before asking permission

  • Privacy: Very important. Close door/curtains.

  • Pain: “Are you in any pain at all?” 

  • Position: Start with patient sitting on couch edge, then lying at 45°

  • Exposure: Exposed to waist, with bra removed

  • Chaperone: absolutely vital. Explain they are there for the patient’s comfort, and to assist you

INSPECTION



At rest, arms by sides




Arm manoeuvres

  • Ask the patient to point to any areas of concern


  • Skin: puckering, inflammation, scars, ulcers, peau d’orange (dimpling), eczematous change, Paget’s disease of the nipple

  • Soft tissue: breast asymmetry, distortion, retraction/inversion - new or old?, discharge?


  • Ask patient to raise arms slowly above head

    • Asymmetry: tethering or fixation of lump to overlying skin

  • Ask patient to push hands again hips and tense (contracts pectoralis muscles)

    • Relationship of lump to pectoral muscles: tethering, fixation

LYMPH NODES

  • Support patient’s arm with yours 

    • Put their hand on your shoulder

  • Feel for axillary lymphadenopathy (medial, apical, anterior, posterior and lateral)

    • Feel around the borders of the armpit: behind pec major, below the arm, in front of lat dorsi

  • Palpate supraclavicular nodes

  • Repeat on the opposite side.

BREASTS


  • Lie patient at 45°, with their hand behind their head


  • Examine asymptomatic breast first

    • Use flat of 2nd, 3rd and 4th fingers to palpate

    • How you examine the breast is not as important as examining the whole breast systematically. 

    • One method is to start at the 12 o’ clock position and work clockwise from the outside towards the nipple.

    • Another method is to examine each quadrant in a grid manner individually

    • Finish by examining nipple areola complex and the axillary tail

  • Repeat the examination for the symptomatic breast

  • Examine the whole breast first before characterising any lumps

  • Perform the lump exam as outlined earlier on any lumps found.

INSPECTION

Discharge

  • If nipple discharge is present, ask the patient to squeeze their nipple to express the discharge themselves. Check for:

    • Colour, consistency

    • Number of affected ducts and their position

    • Can check for blood with a urine dipstick

Cancer

  • If suspicion of metastatic cancer, check for:

    • Lung mets: auscultate for wheeze or pleural effusion

    • Bone mets: palpate length of spine, see if tender over spinous processes

    • Abdomen: palpate for hepatomegaly/ascites

    • Cerebral mets: neuro exam (15% of cerebral mets originate from the breast)

CLOSURE

Closure

  • Thank the patient, ensure they are comfortable and dressed. 

  • Remove PPE

  • Clean equipment and wash hands

To complete


  • Triple assessment

    • Full history and examination

    • Radiology (ultrasound scan if <35yo, mammogram if >35yo

    • Histopathology (fine needle aspirate or core biopsy)