Examination of the Breast Flashcards
Non-Malignant Causes of Breast Lumps
• Benign, hormonal nodularity • Breast pain • Cysts • Itchy nipples/milky discharge Sepsis
Causes of Breast Lumps
• Benign breast change • Fibroadenoma • Cyst • Sebaceous cyst • Papilloma • Fat necrosis/haematoma • Mastitis/abscess • Cancer • Sarcoma, lymphoma, metastases Implant related: (capsule, rupture, edge or crease)
What is a fibroadenoma and what are some details about it?
- Age range: predominantly puberty to 25- 30
- Characteristics: smooth, mobile (breast mouse), non tender.
- Size: usually 1-3 cm.
- Giant variants and multiple juvenile FA
- Phyllodes tumour!
- Management: leave unless increasing in size, atypical histology, tender.
What are the characteristics and management of breast cysts?
Involutional change, Age Range: 35-55
• Size varies from 1mm to 20 cm but on average, symptomatic ones are 1-2 cm and often multiple
• Characteristics: may feel cystic but if tense may be hard and irregular and difficult to tell from cancer
Management: Aspirate symptomatic cysts. Will cease at menopause unless on HRT
What is benign breast change and what are its characteristics?
- Sometimes known as fibrocystic change.
- Age range, puberty to menopause but usually younger end of range.
- Often tender/painful
- Cyclical variation
- Feels like rubbery nodularity
- Management: reassure
History: Questions to ask for Presenting Complaint?
• Duration of symptoms • Tenderness/not • Cyclical nature • Pregnancy/breast feeding • Size increasing? • Nipple discharge/bleeding Previous history of breast problems (cysts, previous cancer)
History: What other questions would you ask?
• Use of oestrogens
• General health
• Drug history, especially clopidogrel, warfarin and apixaban
• Family history of breast or ovarian cancer
• Menopausal status
Breast implants present?
What are the presenting symptoms of Symptomatic Breast Cancer?
- Painless lump/thickening
- Nipple discharge
- Nipple in-drawing
- Distortion
- Paget’s disease
- Axillary nodes
What are the presenting signs of Symptomatic Breast Cancer?
- Painless Lump.
- Irregular
- Hard
- Fixed
• Skin tethering.
Indrawn Nipple
Examination: What are the 2 key stages of a Breast Exam?
INSPECTION and PALPATION
Examination: Describe the Inspection Process
Position the patient so that they are seated comfortably on the edge of the couch and with their arms by their sides
• Inspect for symmetry, not of size or shape between the two breasts as asymmetry is common, but instead look for abnormalities in the contours of each breast e.g. tethering or dimpling of the skin
• Inspect for visible masses
• Inspect for erythema of the skin +/- abnormal scaling (hyperkeratosis and desquamation) of the nipple and areolar skin
• Inspect for nipple retraction (enquire about its duration as this may be normal)
• Ask the patient to raise both arms, put their hands behind their head and push their shoulders back. Inspect the breast tissue whilst the patient performs this manoeuvre. Look for the appearance or accentuation of skin tethering.
• Ask the patient to put their hands on their hip and push inwards. This fixes the pectoralis major and may accentuate lumps tethered to it.
Examination: Describe the Palpation Process
Ask the patient to lie comfortably at 45 degrees. Examination of a large-breasted woman may be easier if their arm is placed above their head.
• Mentally divide the breast into four quadrants (upper outer, upper inner, lower outer and lower inner), plus the axillary tail and nipple.
• Palpate each quadrant, the axillary tail and nipple using the pads of your index, middle and ring fingers (not your fingertips). Make small circular movements as if you were rolling a marble. Increase the level of pressure so that you examine the subcutaneous tissue, mid-level tissue and tissue adjacent to the underlying chest wall.
• Palpate the axillary lymph nodes whilst supporting the patients arm with your free hand (this relaxes the muscles forming the anterior and posterior walls of the axilla and permits easier palpation). Palpate using a rolling action (as above) against the posterior, medial, anterior and apical boundaries of the axilla. If you identify a lump describe its size, (measure with a ruler or calliper if available), consistency, shape and the mobility of the surrounding tissues (is it fixed or mobile?). Also, is it tender on palpation and does it feel hot (inflammatory)?
• Palpate the nipple and inspect for nipple discharge. It is not necessary to attempt to ‘milk’ the nipple to determine whether any discharge is present.
• Examine the supraclavicular fossa for lymphadenopathy.
• If you suspect malignancy, or the patient has a history of malignant breast disease, you should palpate and percuss the abdomen for hepatomegaly (possible liver metastases); and percuss the vertebral spinous processes posteriorly for tenderness (possible vertebral metastases). (In the OSCE, unless you are given specific instructions to perform this assessment, you should simply state to the examiner that you would do so).
Examination: what are the brief areas of inspection?
- Symmetry
- Visible Masses
- Erythema of skin
- Nipple Retraction
- Hands Behind Head for Skin Tethering
- Hands on hips to fix pec major and accentuate lump tethering
Examination: What are the brief areas of palpation?
- Palpate each quadrant, the axillary tail, and nipple using pads of fingers
- Axillary Lymph Nodes
- Palpate Nipple and Look for discharge
- Examine supraclavicular fossa for lymphadenopathy
- if suspecting malignancy: palpate for hepatomegaly and look for tenderness in the vertebral spinous processes for metastases (only if asked in OSCE)
