Examination of the breast

Laura Hopkins
Introduction

Common presentations: pain, lump, discharge,
colour change

Wash hands

Introductions, explain that you need to perform a

breast exam, get consent

Let them know that if at any point they feel

uncomfortable, they can say so and you will stop the
examination

Tell the examiner that you would like the patient at

45°, adequately exposed and that a chaperone
should be present
Inspect
First with arms by their sides

Symmetry, swelling, colour

Scars – lumpectomy, wide local excision,

mastectomy

PASS DIF
 Peau d’orange

 Asymmetry

 Skin changes -erythema

 Scars

 Discharge, Dimpling of skin

 Inversion of the nipple

 Fungating lesion
Inspection

Get her to raise arms above her head and
slowly bring them down by her sides.

Look for tethering of the skin – looks like its

being pulled inside the breast – the skin is
attached to an underlying mass

Get her to press he hands on her hips – may

cause extrusion of a mass when the pectoralis
muscles are activated. i.e. it is attached to the
underlying muscle layers.
Palpation

Ask if there is an area of concern

Start on the opposite breast

Ask if there is any pain

Start away from the site of pain

Remind her that she can stop the exam at any

time

If breasts are very large, try lowering the table –

spreads the breast tissue across the chest
 Palpation

Different routines, find one which suits
you and stick to it.

Ensure you palpate all 4 quadrants of
the breast, use the flats of your fingers,
not the tips.

Palpate around the nipple – 5% of BCA’s
occur here

Lift the breast and palpate underneath

Palpate up the axilliary tail

Feeling for, lumps, nodes, tenderness

For inner quadrants: arm by sides

For outer quadrants: arm behind head

Don’t forget the other breast!

Ask the patient to try and express any
discharge from the nipple – swab it
Axilla

Get patient to rest their arm on
yours, ensure they relax and let
you do all the lifting

Palpate up into the axilla for

lumps, enlarged lymph nodes
or tenderness

Medial, lateral, anterior and

posterior walls of axilla, and the
apicies

Do both axilla
Lumps
4S’s 4T’s and 3C’s

Site

Shape Fixability

Size
Does it move

Surface with the skin?

Temperature
Does it move

Tethering
when pectoral
muscles are

Transilluminate activated? No =

Texture attached to

Colour muscle

Consistency

Capillary – pulsatile and expansile
To finish

Examine other breast if not had the chance, plus
the other axilla, swab any discharge.

I would like to complete my exam by taking a full

history and checking other organ systems

Breast goes to: chest, spine, liver

 Lung bases – pleural effusion
 Spine tenderness – bony mets
 Hepatomegaly – liver mets

The breast exam is part of a triple assessment

 Full history and examination
 Mammography/US (depends on breast tissue
density and age)
 Fine needle aspiration
To finish

Thank the patient

Cover them up ad ensure they are comfortable,

check whether they have any questions

Wash hands

Present findings to examiner

Find yourself a routine and stick to it, as long as

you cover all the areas you will be fine. If it works
for you then just make it slick.
Risk factors for BCA
Risk factors: are major, moderate or minor

- Major: BRACA 1 & BRACA 2 gene,
immediate FH, Breast Ca in the other

breast

- Moderate: Early menarche, late

menopause, use of HRT, use of pill

- Minor: Slender (higher risk) smoking,
drinking ie unhealthy lifestyle
Thanks