Breast Examination

Question 1

State the 5 stages of the breast examination

Answer 1

1. Introduction
2. Inspection
3. Breast palpation
4. Axilla palpation
5. Completing the examination

Question 2

What should you do in the introduction stage of your breast examination?

Answer 2

• Wash your hands
• Introduce yourself (name & role)
• Gain consent
• Offer a chaperone
• Position appropriately
• Expose (remove clothing from waist down and provide blanket for them to cover themselves with when don’t need to be exposed)
• Check for any pain

Question 3

What position do you want pt in for breast examination?

Answer 3

45 degrees supine (once done initial inspection)

Question 4

What should you do in the inspection stage of your breast examination?

Answer 4

• Ask pt to sit on end of bed and relax hands on thighs (to relax pectoral muscles) and inspect for:
  
  • Obvious masses
  • Scars
  • Asymmetry
  • Scars
  • Skin changes e.g.erythema, peau d’orange, puckering
  • Nipple changes e.g. discharge or inversion
  • General health e.g. underweight, pallor
• Ask pt to both hands on hips and push hands into hips to contract their pectoralis muscle and check for the above again
• Ask pt to raise both arms above their head and check for the above again (this will accenuate any asymmetry)
• Ask pt to keep arms above head and lean forwards and check for the above again
  *

Question 5

Why do we ask the pt to do the following in the inspection part of the breast examination:

• Hands pushing into hips
• Arms above head and then lean forward

Answer 5

• Hands pushing into hips: causes pectoralis muscle to contract. This can help determine if mass is tethered to underlying tissue; if it moves up when they contract pectoralis suggests there is tethering and hence may be invasive breast malignancy. May also accentuate puckering if mass is invading suspensory ligament of breast as this is also tethered to pectoralis.
• Arms above head and then lean forward: exposes entire breast and axilla. May exaggerate asymmetry, skin dimpling or puckering

Question 6

What is puckering of the breast tissue?

Answer 6

• Skin drawn inwards
• Associated with invasion of the suspensory ligaments of breast by an underlying malignancy
• Results in ligamentous contraction which draws skin inwards

Question 7

What is peau d’orange?

Answer 7

• Dimpling of skin resembling oragne peel
• Occurs due to lymphatic oedema
• Dimples represent tething of swollen skin to hair follicles & sweat galnds
• Typically associated with inflammatory breast cancer

Question 8

What should you do in the breast palpation stage of the breast examination?

Answer 8

• Begin palpation on asymptomatic breast
• Ask pt to place hand ipsilateral to breast you are examining behind their head
• Numerous methods: e.g. spiral method, start at nipple and work outwards concentrically
• Use flats of middle three fingers to compress breast tissue against chest wall
• If mass is detected assess:
  
  • Location
  • Size
  • Shape
  • Consistency
  • Mobility
  • Fluctuance
  • Overlying skin changes
• Asssess for nipple discharge

Question 9

What is the axillary tail?

Why is it so important to thoroughly examine the axillary tail?

Answer 9

• Projection of breast tissue that begins in upper outer quadrant of breast & extends into axilla
• Majority of breast cancers develop in upper outer quadrant so essential this area is examined thoroughly

Question 10

How do you assess for fluctuance of a mass?

Answer 10

Hold mass between two fingers and compress centre of mass with other finger. If sides bulge outwards= flucutant

Question 11

How do you inspect for any nipple discharge?

Answer 11

• Use flats of 3 middle fingers to compress areolar tissue towards the nipple to squeeze for discharge
• NOTE: ensure you tell pt they should not force discharge this is purely for examination

Question 12

What might the following nipple discharge indicate:

• Milky
• Purulent
• Watery & bloody

Answer 12

• Milky= normal in preg & breastfeeding. May be galactorrhoea
• Purulent= thick yellow, green or brown with offensive smell may indicate mastitis and breast abscess
• Watery & bloody= several causes but ductal carcinoma in situ is most important to consider

Question 13

What should you do in the axilla palpation stage of your breast examination?

Answer 13

• When examining e.g. right axilla, hold pts right forearm in your right hand and instruct them to relax completely allowing you to take the weight
• Palpate axiall with left hand
• Examine axilary lymph nodes (see image)
• Examine cervical, supraclavicular, infraclavicular , parasternal

Question 14

What should you do in the completing your examination stage of the breast examination?

Answer 14

• Thank pt
• Wash hands
• Sumarise findings
• Further assessments and investigations:
  
  • Triple assessment: take history, imaging (mammography or USS) and biopsy