Breast exam script

Question 1

What are the history questions?

Answer 1

• Do you have any current medical conditions?
• Do you have any allergies to any medications, foods, or environmental factors?
• Are you currently on any medications, herbs, or supplements?
• Have you had any surgeries or hospitalizations?
• Are you UTD on your screenings including breast, cervical, and colonoscopies?
• When was your LMP / what is your menstrual status?
• Are you currently using any forms of birth control? Have you ever been or are you currently pregnant? If so, what was the status of your deliveries (vaginal or c-section)?
• Do you have any family history of breast CA, cervical CA, or ovarian CA?

Question 2

What should you say to the patient right before the breast exam?

Answer 2

First we’ll start with the breast exam.
I will start by inspecting one breast at a time, first by palpating while vocalizing my findings, then I will inspect under your arm and will assess your lymph nodes. Please let me know if anything is painful or you would like to stop at any time and I will continue to explain the steps of the exam as we go through them together.

I’ll have you lay back and raise up your right arm above your head and I will start by uncovering your right breast.

Question 3

What should you comment on visually during the breast exam?

Answer 3

• The right breast is free of enlarged pores, any retractions, and dimpling
• The nipple is free of any rashes, ulcers, or inversion.

Question 4

1) What should you say before breast palpation?
2) What should you comment on as you’re palpating clockwise/

Answer 4

1) Now I’ll palpate your right breast, let me know if anything is tender or painful
2) The consistency is soft with no masses or nodules and is nontender to palpation

Question 5

What should you do and say after clockwise palpation of the breast?

Answer 5

“I’m going to assess the nipple and use slight pressure with my hands”
- The areola is free of nodules or lesions.
- Using slight pressure, there is no discharge

Question 6

After you palpate the nipple, what should you visually assess?

Answer 6

Have pt lift arm and look at axillary region:
-There are no rashes, lesions, masses, and pigmentation is even

Question 7

What should you do after you visually inspect the axillary area?

Answer 7

“Now I will have you lower your arm and I am going to assess your lymph nodes, let me know if anything is painful or tender”
- Feeling the supraclavicular, infraclavicular, central, pectoral, lateral, and subscapular lymph nodes; no LAD

Question 8

What should you do after you palpate the lymph nodes?

Answer 8

Now I will cover you back up and begin the left side!
- Repeat steps for left side

Question 9

What should you do after you’ve inspected both breasts?

Answer 9

*After inspecting both breasts
- Both are symmetrical in size and contour with no visible skin changes such as dimpling, Peau d’orange, or retraction
- The nipples are bilaterally symmetrical with no discharge or lesions