What are the first 3 things you should do in a breast exam?
Wash hands
Introduce yourself
Confirm patient details - Name / DOB
Give an example of how you’d explain the examination to a patient.
Today I’ve been asked to perform a breast examination, do you understand what this will involve?”
“The examination will involve me first inspecting the breasts, then placing a hand on the breasts to assess the breast tissue. Finally I will examine the glands of your neck and armpit.”
How would you explain the need for a chaperone?
“One of the female ward staff members will be present throughout the examination, acting as a chaperone, is this ok?”
What 3 questions might you ask to check the patient’s understanding?
- Does everything I’ve said make sense?
- Do you feel you understand what the examination will involve?
- Do you have any questions?
How would you gain consent for a breast examination?
“Are you happy for me to carry out the breast examination?”
How would you like to assess the patient?
- Ask pt to undress down to the waist behind the curtain (provide blanket to cover).
If the pt has presented due to concerns about a lump, what should you ask about?
Ask the pt about the location of the lump.
On general inspection, how would you like to position the patient?
Ask pt to sit upright, ideally on the side of the bed.
Ask pt to uncover breasts at this point.
What should you look for on general inspection?
Any obvious masses, scars or asymmetry
What are the 3 positions you’d like the patient to hold on close inspection?
- Arms by side
- Hands on hips
- Arms above head
What 3 initial features would you look for on close inspection?
Scars: small scars (lumpectomy) / large diagonal scars (mastectomy)
Asymmetry: healthy breasts are often asymmetrical
Masses: note the size & position. Look for overlying skin changes.
During ‘arms by side’ inspection, what 3 skin changes would you look for?
- Erythema: Infection / superficial malignancy
- Puckering: may indicate an underlying malignant mass
- Peau d’orange: cutaneous oedema - inflammatory breast cancer
During ‘arms by side inspection’, what 3 nipple changes would you look for?
Retraction: congenital / underlying tumour / ductal ectasia
Discharge: may indicate infection or malignancy
Scale: may indicate eczema or Paget’s disease
After ‘arms by side’ inspection, what should you do?
‘Hands on hips’ inspection.
- Repeat inspection (scars / asymmetry / masses / skin changes / nipple changes)
During the ‘hands on hips’ inspection, a mass is noticed. What should you check if this is the case?
Observe to see if the mass moves with the pectoralis muscle.
This is known as ‘tethering’ and suggests invasive malignancy.
How should you ask the pt to position themselves for the ‘Arms above head’ inspection?
Ask pt to place both hands behind their head.
What should an ‘arms above head’ inspection involve?
Inspect the breast tissue for any evidence of:
- masses
- asymmetry
- dimpling / puckering
Why should you ask a pt to lean forwards, keeping their hands behind their head?
This position will exacerbate any skin dimpling / puckering which may relate to an underlying mass.
Repeat inspection of the breast tissue, as above.
What 3 areas require palpation?
- Breast
- Axillary tail
- Nipple
Describe how you would palpate the breast.
Examine the “normal” asymptomatic breast first. Ensure to warm your hands before touching the patient.
Position the patient laid on the bed at a 45 degree angle.
Ask the patient to place their hand on the side being examined behind their head.
Use the flat of your fingers to compress the breast tissue against the chest wall, feeling for any masses.
Use a systematic approach to ensure all areas of the breast are examined:
Clock face method – examine each “hour” of the breast
Spiral method – start at the nipple and work outwards in a concentric circular motion
If a mass is detected, ensure you complete a thorough examination of the remaining breast tissue before examining the mass further.
Describe how you would palpate the axillary tail of breast tissue
- Breast tissue often extends into the axilla & is known as the ‘axillary tail’.
- Majority of breast cancers develop in the upper outer quadrant, so it’s essential this area is examined thoroughly.
Describe how you would investigate nipple discharge.
If pt reports having nipple discharge, ask them to squeeze the nipple to demonstrate this.
Yellow / green discharge: suggestive of infection
Bloody discharge: more suspicious of malignancy eg. papilloma.
Repeat palpation on the other breast, asking the patient to place their alternate hand behind their head.
What are the 6 key features you should look for when examining a breast lump?
- Position
- Size & shape
- Consistency
- Overlying skin changes
- Mobility
- Fluctuance
What 3 questions should you consider regarding the position of a lump?
- Which quadrant of the breast is the mass located within?
- Using the clock face metaphor, what ‘hour’ on the clock is the mass located at?
- How far away from the nipple is the mass located?
