The Breast Examination

Introduction

• Introduce yourself to the patient
• Wash your hands
• Explain to the patient what the examination involves
  • Important to check the patients understanding of the examination
• Position the patient at 45^o

• Ensure a chaperone is present during the examination
• Ask the patient to remove their clothing to expose their chest, from above the waist
  • Provide a blanket for the patient to cover themselves when not required to expose the breasts

Inspection

• Inspect the patient from the end of the bed
  • Check for any obvious masses, scars, or asymmetry

• Ask the patient to place their hands by their sides, comparing both breasts
• Check for any obvious scars or masses present
  • Note the size and position of any observed
• Look for any skin changes or ulceration
  • Erythema, puckering, or peau d’orange (orange peel appearance due to oedema)
• Look for any nipple changes
  • Nipple discharge or inversion

• Ask the patient to place both hands behind their head and repeat this inspection
  • This will accentuate any asymmetry

• Inspect the axillae for any obvious masses

• Ask the patient to place both hands on their hips and repeat this inspection
  • This will accentuate any asymmetry

Palpation

• Ask the patient to place both hands behind their head
• Examine each quadrant of the breast in turn, including the axillary tail (also termed the “Tail of Spence”)
• Using a flat hand, press the breast against the underlying chest wall, rolling the underlying tissue
  • Start with the ‘normal’ side first, examining any painful areas last
• If you palpate any lumps, note their position, size, shape, consistency, overlying skin changes, and mobility.
  • Examine their fixity to pectoralis muscles by asking the patient to push against your hand with their hand outstretched

• Examine both axilla in turn
  • When examining the right axilla, hold the patients right arm with your right hand and examine the axilla with your left hand
  • When examining the left axilla, hold the patients left arm with your left hand and examine the axilla with your right hand
• Palpate for any lymphadenopathy
  • 5 sets of axillary lymph nodes are present: apical, anterior, central, posterior, and medial

• To fully examine a breast, you should also remember to assess for potential metastasis:
  • Palpate the spine for tenderness
  • Palpate the abdomen for hepatomegaly
  • Percuss and auscultate the lungs for lung masses

Completing the Examination

Thank the patient and ask them to redress

To finish the examination, stand back from the patient and state to the examiner that to complete your examination, you would like to follow up your examination with:

• Mammography and / or ultrasound, if necessary
• Biopsy (core needle or fine needle aspirate), if necessary