Breast history and examination

Question 1

Breast history: What direct questions should you ask someone presenting with a breast lump?

Answer 1

Previous lumps?
Family history?
Pain?
Nipple discharge?
Nipple inversion?
Skin changes?
Change in size related to menstrual cycle?
Number of pregnancies?
First/last/latest period?
Postnatal?
Breast feeding?
Drugs, e.g. HRT?
Consider metastatic disease: weight loss, breathlessness, back pain, abdominal mass?

Question 2

Breast history: What direct questions should you ask someone presenting with breast pain?

Answer 2

SOCRATES.
Bilateral/unilateral?
Rule out cardiac chest pain.
History of trauma?
Any mass?
Related to menstrual cycle?

Question 3

Breast history: What direct questions should you ask someone presenting with nipple discharge?

Answer 3

Amount?

Nature: colour, consistency, any blood?

Question 4

Breast history: What questions should you ask about past history?

Answer 4

Any previous lumps and/or malignancies?

Previous mammograms, clinical examinations of the breast, USS, FNA/core biopsies?

Question 5

Breast history: What questions should you ask about drug history?

Answer 5

Ask specifically about HRT and the Pill.

Question 6

Breast history: What questions should you ask about family history?

Answer 6

Breast cancer in the family?

Question 7

Breast history: What questions should you ask about social history?

Answer 7

Try to gain impression of support network if suspect malignancy.

Question 8

Breast history: What are the causes of breast pain (including non-breast)?

Answer 8

Is it premenstrual (cyclical mastalgia)?
Breast cancer (refer, e.g. for mammography if needed).
If non-malignant and non-cyclical…
Tietze’s syndrome (costochondritis plus swelling of the costal cartilage).
Bornholm disease/Devil’s grip (Coxsackie B virus, causing chest and abdominal pain, which may be mistaken for cardiac pain or an acute surgical abdomen, resolves within 2wks).
Angina.
Gallstones.
Lung disease.
Thoracic outlet syndrome.
Oestrogens/HRT.
If none of the above, wearing a firm bra all day may help, as may NSAIDs.

Question 9

Breast history: What are the causes of nipple discharge?

Answer 9

Duct ectasia (green/brown/red, often multiple ducts and bilateral).
Intraductal papilloma/adenoma/carcinoma (bloody discharge, often single duct).
Lactation.

Question 10

Breast history: What is the management plan for nipple discharge?

Answer 10

Diagnose the cause (mammogram, ultrasound, ductogram), then treat appropriately.
Cessation of smoking reduces discharge from duct ectasia.
Microdochetomy/total duct excision can be considered if other measures fail, though may give no improvement in symptoms.

Question 11

Breast examination: General inspection

Answer 11

CHAPERONE.
Introduction, consent, position patient sitting at edge of bed with hands by side, expose to waist.
Inspect both breasts for obvious masses, contour anomalies, asymmetry, scars, ulceration, skin changes.
Assess size and shape of any masses as well as overlying surface. Which quadrant?
Note skin involvement, ulceration, dimpling (peau d’orange), and nipple inversion/discharge.
Ask her to “press hands on hips” and then “hands on head” to accentuate any asymmetrical changes.
While patient has her hands raised inspect axillae for any masses as well as inspecting under the breasts.

Question 12

Breast examination: Palpation of the breast

Answer 12

Position patient sitting back at 45 degrees with hand behind head (e.g. right hand for right breast).
Ask patient if she has any pain or discharge.
Examine painful areas last and then ask her to express any discharge.
Examine each breast with the ‘normal’ side first.
Examine each quadrant in turn as well as the axillary tail of Spence, or use a concentric spiral method.
Use flat hand to roll breast against underlying chest wall.
Define any lumps/lumpy areas.
If you discover a lump, to examine for fixity to the pectoral muscles ask the patient to tense her chest again, e.g. push hands on hips.
Is it fluctuant/compressible/hard? Temperature? Tender? Mobile?

Question 13

Breast examination: Palpation of the axillae

Answer 13

Examine both axillae.
Metastatic spread? Ipsilateral/bilateral? Matted? Fixed?
When examining right axilla, hold patient’s right arm with right hand and examine axilla with left hand.
5 sets of axillary lymph nodes:
1) apical (palpate against glenohumeral joint).
2) anterior (palpate against pectoralis major).
3) central (palpate against lateral chest wall).
4) posterior (palpate against latissimus dorsi).
5) medial (palpate against humerus).

Question 14

Breast examination: Further examination and completion

Answer 14

Complete the examination by palpating down the spine for tenderness, examining abdomen for hepatomegaly, and lungs for signs of metastases.
Thank patient and wash hands.
Refer for mammogram/USS and FNA/core biopsy.