Breast Examination: Skills Training Manual Book Basic Surgical Skills Year Ii

SKILLS TRAINING MANUAL BOOK
BASIC SURGICAL SKILLS

YEAR II
BLOCK 2.5
BREAST EXAMINATION
Skills Laboratory
Faculty of Medicine
Universitas Gadjah Mada
2010
BREAST EXAMINATION
BLOCK 2.5
Contributor:
dr. Kunta Setiadji, Sp.B (K) Onk
Oncology Subdivision, Department of Surgery
Faculty of Medicine Universitas Gadjah Mada/ Dr. Sardjito General Hospital
Yogyakarta
dr. Artanto Wahyono, Sp.B
Oncology Subdivision, Department of Surgery
Faculty of Medicine Universitas Gadjah Mada/ Dr. Sardjito General Hospital
Yogyakarta
Co-Contributor:
dr. Yulia Wardhani
Assistant of Content Development Team for Skills Training

Faculty of Medicine, Universitas Gadjah Mada
Yogyakarta
Educational Design Reviewed by

dr. Rachmadya Nur Hidayah
Year II Coordinator for Clinical Skills Training
Faculty of Medicine
Universitas Gadjah Mada
PREFACE
Medical faculty students should study and practice several clinical skills as
preparation for entering clinical rotation prior to becoming a certified doctor. Currently,
the medical profession compels medical students to be competent in clinical skills before
they directly deal with real patients experiencing real life medical cases. For this reason,
clinical skills are trained as early as possible. This clinical skills laboratory provides
opportunity for students to study and practice the clinical skills on their own.
The topic of this manual is one of the clinical skills topics that constitute the main
topic of Basic Surgical Skills, which will be studied continually in blocks throughout
undergraduate studies. Topics covered in the Basic Surgical Skills, which will be studied
in Year II, are as follows:
No.
Topics for Clinical Skills Training
1. Simple Skin Suturing
Block
2.1
( Conception, Foetal
Growth and Congenital
Anomaly)
2.
Circumcision
2.3
(Childhood)
3.
Breast Examination
2.5
(Adulthood)
It is important for students to recognize that all topics, including those listed
above, are interrelated. Therefore, students are expected to categorize the topics based on
the main topics, so that continuity from one topic to another can be achieved. We hope
that in the future, this manual for clinical skills training can be useful for students to
improve their skills, especially in physical examination; and for instructors who are
involved in providing the trainings.
Yogyakarta, February 2010
Contributor
TABLE OF CONTENTS
Preface
Table of Contents
Introduction
Objectives
Basic Concept
Anatomy of the breast
Common Breast Masses
Risk Factors for Breast Cancer
Visible Signs of Breast Cancer
Technique of Examination
The Female Breast
Anamnesis (Review of Specific Symptom)
Physical Examination
Inspection
Axillary Examination
Palpation
Examination of the nipple
The Male Breast
Breast Self-Examination
Lesson Plan for Breast Enamination
Objectives
Activities
Tools
Level of Competences
References
Checklist Breast Examination
Checklist Breast Examination
Checklist Teaching Breast Self Examination
Appendix 1 -- Sex Maturity Ratings In Girls : Breasts
Appendix 2 -- Safety Precaution
LESSON PLAN OF
BREAST EXAMINATION
A. General Objectives of Skills Training Year II
1. Students are able to explore data (communication, physical, procedural,
supporting examinations) and draw a conclusion from patients problems, the
sequence of diagnosis possibilities as well as to deliver the results to the patient.
2. Students are able to perform specific procedural actions relevant to patients
problems, by considering ethical aspects.
B. General Objectives of Breast Examination
1. Perform anamnesis on breast complaint.
2. Perform the breast examination by physician
3. Demonstrate techniques for breast self-examination to the patient
4. Determine the supporting examination to establish the diagnosis.
C. Level of Competence
Level of Competence for Clinical Skills :
The following is the division of competence level according to Miller Pyramid:
Level of Competence 1: Understanding and Explaining
The graduates of medical school possess theoretical knowledge concerning these
skills, so that they are able to explain concepts, theories, principles or indications,
performing procedures, emerging complications and others to their colleagues.
Level of Competence 2: Having seen or Having been demonstrated
The graduates of medical school possess theoretical knowledge concerning this
skill (concepts, theories, principles or indications, performing procedures,
complications and others). Besides, during their study, they had seen this skill or
this skill had been demonstrated to them.
Level of Competence 3: Having done or Having applied under supervision
this skill had been demonstrated to them or they had applied several times under
supervision.
Level of Competence 4: Able to perform independently
this skill had been demonstrated to them and they had applied several times under
supervision; in addition, they possess experience to use and apply this skill in the
context of doctor practices independently.
Physical Examination
Inspection of breasts
Palpation of breasts
Level of Expected Ability

1
2
3
4
1
2
3
4
General physical examination including breasts

Instruction for self-examination of breasts
1
1
2
2
3
3
4
4
D. Activities
First Session
No. Duration
1.
5 mins
Topics
Introductions
2.
15 mins
Review of History
Taking
3.
15 mins
4.
15 mins
Breast
examination
demonstration
Breast
examination
review and check
5.
30 mins
Practices
6.
10 mins
Break
Question and
answer
7.
30 mins
Practices
Second session
No. Duration
1.
15 mins
Topics
Introduction
Review
2.
15 mins
Overview and
demonstration
of BSE
3.
20 mins
BSE review and

check
Tools
Trainer introduce himself/herself
and gives general precautions of
the tools used in his session
Trainer discuss with the students
what is important in history taking,
ask the students to recall and
structure the question
Trainer demonstrate the
examination on a student, step by
step breast examination
One of the student demonstrate the
examination on other student
The other student give comments
and corrections. The demonstrator
may ask for doubt and difficulties
Students grouped to practice the
examination
Students sharing their doubts
,difficulties and comments after
first practices.
If there is no question
Trainer remind the important
things
examination
Vest
Vest
Vest
Vest
Tools
Trainer ask the students the
important things of History
Taking and breast examination
Trainer explains the importance
of BSE in the early diagnosis of
breast abnormalities, when to
do, how to do it
Using flip chart
One of the student demonstrate
the examination on other
Vest
Flip
chart
Vest
Flip
4.
30 mins
Practices
5.
10 mins
Break
Question and
answer
6.
30 mins
Practices
E. Tools
1. Manual Book
2. Breast Vest
3. Breast Self Examination Simulation
4. Breast Care Flip Chart
5. Breast Self Exam Form
6. Alkohol 70%
7. Gloves
student
The other student give
comments and corrections. The
demonstrator may ask for doubt
and difficulties
examination
Students sharing their doubts
,difficulties and comments after
first practices.
If there is no question
Trainer remind the important
things
examination
chart
Illustration Case
A 28-year-old woman came to you, complaining of a lump at her breast, which she
suffered-from, since 2 years ago. The lump did not getting bigger and was painless.
How to conduct breast examination to this patient?
Give guidance how to perform self breast examination!
Introduction
Breast cancer is the most common cancer in women worldwide, accounting for
more than 10% of all female malignancies. In the United States, the National Cancer
Institute estimates that 1 woman of every 8 (approximately 12.6%) will develop breast
cancer during her lifetime. Among the malignancies in women, breast cancer is the most
common cancer to develop and is the second most common cancer cause of death. It
accounts for 26% of new cancers in American women and 18% of cancer deaths. In 2000,
there were 184,200 new cases with 41,200 deaths in the United States. Mortality rates
have declined for white women younger than 55, probably as a result of more widespread
use of mammography and aggressive treatment regimens, but have increased for African
American women.
Once breast cancer has occurred in a family, the risk for other women in the same
family will develop breast cancer is significantly higher. First degree relatives, such as
sisters or daughters, have more than twice the risk of developing breast cancer if the
original patients developed cancer in one breast after menopause.Women with a family
history of premenopausal breast cancer in one breast have three times the risk If the
original patient had postmenopausal cancer in both breasts, the first degree relatives have
more than four times the risk. First-degree relatives of patients with cancer in both breasts
before menopause have nearly nine times the risk.
For screening of asymptomatic women target risk factors, including family
history. Risk factors for breast cancer are present in up to 55% of cases, and a positive
family history is present in additional 10%. The clinician and individual patient should
review age and demographic data, family history, reproductive history, and any prior
history of proliferative breast disease, especially if a biopsy has shown atypical
hyperplasia or lobular carcinoma in situ.
Rarely, men report about a breast mass. Breast cancer in men accounts for 1% of
all breast cancers and is usually diagnosed between the ages of 60 and 70. Risk factors
include estrogen exposure, including excess estrogen stimulation in Klinefelters
syndrome or cirrhosis, radiation exposure, and positive family history in female relatives.
Most common breast cancers are detected as painless masses noticed by either
the patient or the examiner during a routine physical examination. The earlier the
diagnosis, the better the prognosis. Screenings for breast cancer are best done by a
thorough clinical breast examination, breast self examination, and mammography.
Mammography is the most sensitive method for the detection of breast cancer and has
been demonstrated to reduce the breast cancer mortality rate recently.
BASIC CONCEPT
Anatomy of the breast
The female breast lies against the anterior thoracic wall, extending from the
clavicle and 2nd or 3rd rib down to the 6 th or 7th rib, and from the sternum across to the
midaxillary line. Its surface area is generally rectangular rather than round. The breast
overlies the pectoralis major and at its inferior margin, the serratus anterior.
Figure 1. The Breast and Axillae

Source: Bickley L.S. dan Szilagyi P.G. Bates Guide to Physical Examination
and
History Taking. 9th edition. Lippicott Williams & Wilkins.
2007
To describe clinical findings, the breast is often divided into four quadrants based
on horizontal and vertical lines crossing at the nipple. An axillary tail of breast tissue
extends toward the anterior axillary fold (see figure 2).
The normal breast consist s of glandular tissue, ducts, supporting muscular tissue,
fat, blod vessels, nerves, and lymphatics. The glandular tissue consists of 15-25 lobes,
each of which drains into a separate excretory duct that terminates in the nipples. Each
ducts dilates as it enters the base of the nipple to form a milk sinus. This serves as a
reservoir for milk during lactation. Each lobe is subdivided into 50-75 lobules, which
drain into s duct that empties into the excretory duct of the lobe. Fibrous connective
tissue provides structural support in the form of fibrous bands or suspensory ligaments
connected to both the skin and the underlying fascia. Adipose tissue, or fat, surrounds the
breast, predominantly in the superficial and peripheral areas. The proportions of these
components vary with age, the general state of nutrition, pregnancy, exogenous hormone
use, and other factors.
Fig. 2
Fig. 3
Source: Bickley L.S. dan Szilagyi P.G. Bates Guide to Physical Examination and
History Taking. 9th edition. Lippicott Williams & Wilkins. 2007
The blood supply to the breast is carried by the internal mammary artery. The
breast has an extensive network of venous and lymphatic drainage. Most of the lymphatic
drainage empties into the nodes in the axilla. Other nodes lie beneath the lateral margin of
the pectoralis major muscle, along the medial side of the axilla, and in the subclaviar
region. The main lymph node chains and lymphatic drainage of the breast are shown in
figure 4.
Fig. 4. Lymphatic drainage of the breast

Examination .
Source: Swartz, M.H. Textbook of Physical Examination : History and

4th edition. W.B. Saunders Company. 2002
Common Breast Masses

The three most common kinds of breast masses are fibroadenoma (a benign
tumor), cysts, and breast cancer. The clinical characteristics of the masses are listed
below (table 1.). However, any breast mass should be carefully evaluated and usually
warrants further investigation by ultrasound, aspiration, mammography, or biopsy. Ideally
the breast cancer should be identified early, when the mass is small.
Fibroadenom
a
Cysts
Cancer
15-25, usually
puberty and young
adulthood, but up
to age 55
Usually single,
may be multiple
30-50, regress
after menopause
except with
estrogen therapy
Single or multiple
round
Delimitation
Round, disclike,
or lobular
May be soft,
usually firm
Well delineated
30-90, most common

over 50in middleaged and elderly
women
Usually single,may
coexist with other
nodules
Irregular or stellate
Mobility
Very mobile
Mobile
Tenderness
Usually nontender
Often tender
Usual Age
Number
Shape
Consistency
Soft to firm,
usually elastic
Well delineated
Firm or hard
Not clearly delineated
from surrounding
tissue
May be fixed to
skinor underlying
tissue
Usually nontender
Retraction Sign Absent

Absent
May be present
Table 1. Characteristics of the Common Breast Masses
Risk Factors for Breast Cancer

Age. More than three fourths of breast cancer cases occur in women 50 years or
older; more than half in women older than age 65. For women between the ages
of 35 and 55 without major risk factors, the chance of developing breast cancer is
approximately 2.5%.
Family History. Risk from familial breast cancer falls into two patterns: family
history of breast cancer and genetic predisposition. First-degree relatives, namely
a mother or sister with breast cancer, establish a positive family history.
history. Within thisgroup, menopausal status and extent of disease play a key
role. Having first degree relatives with breast cancer who are premenopausal with
bilateral disease confers the highest risk.
Menstrual History and Pregnancy. Early menarche, delayed menopause,and

first live birth after age 35 or no pregnancy all raise the risk of breast cancer twoto three-fold.
Breast Conditions and Diseases. Benign breast disease with biopsy findings of
atypical hyperplasia or lobular carcinoma in situ carry significantly increased
relative risks4.4 and 6.9 to 12.0, respectively.
History of Radiation Treatment. Chances for developing breast cancer are
higher if someone had chest-area radiation treatment during childhood or early
adulthood.
Visible Signs of Breast Cancer

Retraction Signs
As breast cancer advances, it causes fibrosis (scar tissue). Shortening of this tissue
produces dimpling, changes in contour, and retraction or deviation of the nipple. Other
causes of retraction include fat necrosis and mammary duct ectasia. ( see figure 5.)
Abnormal Contour
Look for any variation in the normal convexity of each breast, and compare one side with
the other. Special positioning may again be useful. Shown here is marked flattening of the
lower outer quadrant of the left breast. (see figure 6.)
Fig. 5
Fig. 6
Skin Dimpling
Look for this sign with the patients arm at rest, during special positioning, and on
moving or compressing the breast, as illustrated in figure 7.
Nipple Retraction and Deviation
A retracted nipple is flattened or pulled inward. It may also be broadened, and feel
thickened. When involvement is radially asymmetric, the nipple may deviate or point in a
different direction from its normal counterpart, typically toward the underlying cancer.
(see figure 8.)
Fig. 7
Fig. 8
Edema of the skin

Edema of the skin is produced by lymphatic blockade. It appears as thickened skin with
enlarged pores the so-called peau dorange (orange peel) sign. It is often seen first in
the lower portion of the breast or areola.( figure 9.)
Pagets Disease of the Nipple
This is an uncommon form of breast cancer that usually starts as a scaly, eczemalike
lesion. The skin may also weep, crust, or erode. A breast mass may be present. Suspect
Pagets disease in any persisting dermatitis of the nipple and areola. (figure 10.)
Fig. 9
Fig. 10
Investigations
Although an accurate history and clinical examination are still the most important
methods of detecting breast disease, there are a number of investigations that can asist in
the diagnosis:
Mammography. Soft-tissue radiographs are taken by placing the breast in direct
contact with ultrasensitive film and exposing it to low-voltage, high-ampere x-
rays. The dose of radiation is approximately 0.1 Gy, and therefore mammography
is very safe investigation which can be repeated.
Ultrasonography is particularly useful in young women with dense breast in
whom mammograms are difficult to interpret, and in distinguishingcyst from solid
lesions. It can also be used to localize impalpable breast lumps.
Needle biopsy/cytology. Histology can be obtained using a fine needle such as a
Tru-cut or Core-cut biopsy device under local anesthesia. Cytology is obtained
using a 21 0r 23 gauge needle and 10 ml syinge with multiple passes throughout
the lump without releasing the negative pressure in the syringe. The aspirate is
then smeared onto a slide which is air dried. Fine needle aspiration cytology
(FNAC) or Fine needle aspiration Biopsy (FNAB) is the least invasive tecnique
for obtaining a cell dagnosis, and is very accurate if both operator and cytologist
are experienced. However, false negativess d occur mainly through sampling
error, and invasive cancer cannot distinguished from carcinoma in situ.
Ductography demonstrates duct anatomy and pathology by injection of radioopaque contrast medium into a major lacteal duct and taking a radiograph. It is a
painful technique, rarely of value except in certain obsure cases of discharge
TECHNIQUE OF EXAMINATION
THE FEMALE BREAST
ANAMNESIS ( Review of Specific Symptoms)
The most important symptoms of breast disease are the following:
Symptom
MASS or
SWELLING
The Following Questions

When did you first notice the lump?
Have you noticed that the mass changes in size during your
menstrual periods?
Is the mass tender?
Have you ever noticed a mass in your breast before?
Have you had any recent injury to the breast?
Is there any nipple discharge? Nipple retraction?
Do you have breast implant?If so, What are they made of?
If the lump enlarged during menstrual stages of the cycles, it is
likely that the women is detecting only physiologic nodularity.
Presence of nipple discharge,nipple inversion,skin changes is
strongly suggestive of neoplasma.
PAIN
Can you describe the pain?

When did you first experience the pain?
Are there any changes in the pain with your menstrual
cycles?
Do you have pain in both breast?
Have you had any injury to the breast?
Is the pain associated with a mass in the breast? Nipple
discharge? Nipple retraction?
Has there been a change in your bra size?
Breast pain is a common symptom. Most often, these
symptoms are due to the normal physiologic cycle. Rapidly
enlarging cysts may be painful. Cystic disease of the breasts is
usually painless. Although breast pain is a relatively
uncommon presentation of breast cancer, its presence does not
exclude the diagnosis.
NIPPLE
DISCHARGE
What is the color of the discharge?

Do you have a discharge from both breast?
When did you first notice the discharge?
Is the discharge related to your menstrual cycles?
When was your last menstrual cycle?
Is the discharge associated with nipple retraction? a breast

mass? breast tenderness?
Do you have headache?
Are you taking any medication?
Are you using oral contraceptives?
Nipple discharge is not a common symptom, but it should
always raise the suspicion of breast disease. The most common
discharge are serous and bloody. A serous discharge is thin and
watery. This commonly result s from an intraductal papilloma
in one of the large subareolar ducts. A bloody discharge is
associated with an intraductal papilloma, which is common
among pregnant and menstruating women. A serous discharge
can also occur in breast carcinoma. It may be associated with a
malignant intraductal papillary carcinoma. A milky discharge
is usually milk.
CHANGE IN
SKIN OVER
BREAST
A change in the color or texture of the skin of the breast or

areola is an important symptom of the breast carcinoma. The
presence of dimpling, puckering, or scaliness warrants further
investigation. The present of unusually prominent pores,
indicative of edema of the skin, called peau dorange because
of its orange-peel appearance. Limited peau dorange over the
lower half of the areola is present. As the disease progresses,
more lymphatics become filled with carcinoma cells that block
them, creating more generalized edema.
GENERAL
The interviewer should pay special attention to the family
SUGGESTION history of any woman presenting with symptoms of breast
disease. As indicated earlier, brest cancer may be a familial
disorder. The occurrence of breast disease in a close relative
and the age at which it developed are relevant to the patients
disease.
Ask the patient:
Have you had a mammogram? If so, When and what was
the result?
Have you had breast cancer?
Have you had any breast biopsies or breast surgery?
Have you ever had radiation treatments to your breasts?
Did your natural mother have breast cancer? If yes, Pre- or
post-menopausal? At what age was her diagnosis made?
Do you have a sister or daughter with breast cancer? If yes,
Pre- or post-menopausal? At what age was her diagnosis
made?
Do you use birth control pills?
Do you take estrogen replacement therapy?

PHYSICAL EXAMINATION
No special equipment is necessary for the examination of the breast. The examination
of the breast consists of the following:
Inspection
Axillary examination
Palpation
The examination of the breast is in two parts. The first is performed with the patient
sitting up. Inspection of the breasts and palpation of the lymph nodes are done in this
position. The second is performed with the patient lying down. The examiner
systematically palpates the entire breast by using firm, gentle pressure exerted by the pulp
of the finger rather than the fingertips.
[ INSPECTION ]
The women should be seated on the edge of the examination table, facing the
examiner. The examiner should ask the women to ask the woman to remove her gown to
her waist. A thorough examination of the breast are inspected as to size, shape, symmetry,
contor, colour, and edema in four views: arms at sides, arms over head, arms pressed
against hips, and leaning forward. The nipples are inspected as to size, shape,
inversion, eversion, or discharge. When examining an adolescent girl, assess her breast
development according to Tanners sex maturity ratings (see the appendix 1).
Arms at Sides.
Note the clinical features listed below.
The appearance of the skin, including
- Color, the redness or erythema is associated with infection and inflammatory
carcinoma of the breast.
- Thickening of the skin and unusually prominent pores, which may accompany
lymphatic obstruction, it suggest breast cancer.
The size and symmetry of the breasts. Some difference in the size of the breasts,
including the areolae, is common and is usually normal, as shown in the figure 11.
The contour of the breasts. Look for changes such as masses, dimpling, or
flattening. Compare one side with the other.
The characteristics of the nipples, including size and shape, direction in which
they point, any rashes or ulceration, or any discharge. Asymmetry of directions in
which nipples point suggests an underlying cancer
Fig. 11. Arms At Side

Arms Over Head; Hands Pressed Against Hips; Leaning Forward.

To bring out dimpling or retraction that may otherwise be invisible, ask the patient to
raise her arms over her head, then press her hands against her hips to contract the pectoral
muscles. This maneuver tenses the pectoralis muscles, which may bring out dimpling
caused by fixation of the breast to the underlying muscles. Inspect the breast contours
carefully in each position. If the breasts are large or pendulous, it may be useful to have
the patient stand and lean forward, supported by the back of the chair or the examiners
hands, and allow her breasts to hang free from the chest wall.
Dimpling or retraction of the breasts in

these positions suggests an underlying
cancer.When a cancer or its associate
fibrous strands are attached to both the
skin and the fascia overlying the pectoral
muscles, pectoral contraction can draw the
skin inward, causing dimpling.
Fig. 12. Arms Over Head
Source: Bickley L.S. dan Szilagyi P.G. Bates Guide
to Physical Examination and History Taking. 9th edition.
Lippicott Williams & Wilkins. 2007
Occasionally, these signs may be

associated with benign lesions such as
posttraumatic fat necrosis or mammary
duct ectasia, but they must always be
evaluated with great care.
Fig. 13. Hands Pressed Against Hips
This position may reveal an asymmetry of

the breast or nipple not otherwise visible.
Retraction of the nipple and areola
suggests an underlying cancer.
Fig. 14. Leaning Forward

[ AXILLARY EXAMINATION ]
The axillary examination is performed with the patient seated facing the examiner.
Examination of the axilla is best accomplished by relaxing the pectoral muscles. To
examine the right axilla, the patients right forearm is supported by the examiners right
hand. The tips of the fingers of the examiners left hand start low in the exilla, and, as the
patients right arm is drawn medially, the examiner advances the left hand higher into the
axilla. This technique is shown in figure 15 and 16. Palpate the supraclavicular,
subclavian, and axillary region.
Fig. 15 and 16. Technique for axillary examination

Examination .
The technique of using small, circular motion of the fingers riding over the ribs is
used for detecting adenopathy. Freely mobile nodes 3-5 mm in diameter are common and
are usually indicative of lymphadenitis secondary to minor trauma of the hand and arm.
After one axilla is examined, the other is evaluated by the examiners opposite hand.
[ PALPATION ]
The women is asked to lie down and is told that palpation of the breast is next.
The examiner stands at the right side of the patients bed. Although the examiner can
usually palpate each breast from the patients right side, it is often better with largebreasted women to examine the left breast from the left side.
The breast is best palpated by allowing it to lie evenly distributed over the chest
wall. Small-breasted women may lie with their arms at their sides, larger-breasted women
should be instructed to place their hands behind their head. A pillow placed beneath the
shoulder on the side being examined facilitates the examination.
In palpation of the breast, the examiner should use both the flat of the hand and
the fingertips. Palpation should be performed by the spokes of a wheel, concentric
circle, or the vertical strip method.
A. Spokes of a Wheel (Wedge) Methode
The spokes of a wheelmethod starts at the nipple (Fig 17 & 18). The examiner
should start the palpation by moving outward from the nipple to the 12 oclock
position. The examiner then should return to the nipple and move along the 1 oclock
position and continue the palpation around the breast
Fig. 17 & 18 . Spokes of a Wheel Method

Examination .
B. Concentric Circles (Circular) Method

The concentric circles approach also starts at the nipple, but the examiner moves from
the nipple in a continuous circular manner around the breast.
Fig. 19 & 20. Concentric Circles Method

Examination .
C. Vertical Strip (Grid) Method

Another method is the vertical strip, or grid technique. The breast is divided into eight
or nine vertical strips, each approximately one finger-width wide. Plan to palpate a
rectangular area extending from the clavicle to the inframammary fold or bra line, and from
the midsternal line to the posterior axillary line and well into the axilla for the tail of the
breast. The examiners three middle fingers (the 2nd, 3rd, and 4th fingers, keeping the
fingers slightly flexed) are held together and slightly bowed to ensure contact with the
skin. The pads, not the tips, of the fingers, must be used for palpation. Using
dimensized circles, the examiner evaluates the breast at each of three different levels
of pressure light, medium, and deep. Each strip consists of nine or ten areas of
palpation, slightly overlapping the previous area, and each vertical strip is evaluated
with the three pressures. Although this method has been shown to be superior to the
other traditional types of breast palpation, it is more time-consuming and may be best
used by women for breast self-examination. These technique are illustrated in
figure17 and 18.
Fig. 21 and 22. Vertical Strip Method

To examine the lateral portion of the breast, ask the patient to roll onto the
opposite hip, placing her hand on her forehead but keeping the shoulders pressed
against the bed or examining table. This flattens the lateral breast tissue. Begin
palpation in the axilla, moving in a straight line down to the bra line, then move
the fingers medially and palpate in a vertical strip up the chest to the clavicle.
Continue in vertical overlapping strips until you reach the nipple, then reposition
the patient to flatten the medial portion of the breast.
To examine the medial portion of the breast, ask the patient to lie with her
shoulders flat against the bed or examining table, placing her hand at her neck and
lifting up her elbow until it is even with her shoulder. Palpate in a straight line
down from the nipple to the bra line, then back to the clavicle, continuing in
vertical overlapping strips to the midsternum.
Describe the Findings in Palpation
Consistency of the tissues. Normal consistency varies

widely, depending in part on the relative proportions of firmer glandular tissue
and soft fat. Physiologic nodularity may be present, increasing before menses.
There may be a firm transverse ridge of compressed tissue along the lower margin
of the breast, especially in large breasts. This is the normal inframammary ridge,
not a tumor.
Tenderness, as in premenstrual fullness
Nodules. Palpate carefully for any lump or mass that is

qualitatively different from or larger than the rest of the breast tissue. This is
sometimes called a dominant mass and may reflect a pathologic change that
requires evaluation by mammogram, aspiration, or biopsy. Assess and describe
the characteristics of any nodule:
Locationby quadrant or clock, with centimeters from the nipple
Sizein centimeters
Shaperound or cystic, disclike, or irregular in contour
Consistencysoft, firm, or hard
Delimitationwell circumscribed or not
Tenderness
Mobilityin relation to the skin, pectoral fascia, and chest wall. Gently move
the breast near the mass and watch for dimpling.
[EXAMINATION OF THE NIPPLE]
Examination of the nipple concludes the examination of the breast. Inspect for
nipple retraction, fissures, and scalling. To examines for discharge, place each hand on
either side of the nipple and gently compress the nipple, noting the character of any
discharge. This technique is shown in figure 23 and 24. Ask the women whether she
would prefer to do this part of the examination herself.
Fig. 23 & 24. Technique for nipple examination

Source: Swartz, M.H. Textbook of Physical Examination : History and Examination.
Another methode to examine spontaneous

nipple discharge is shown in figure 25. If
there is a history of spontaneous nipple
discharge, try to determine its origin by
compressing the areola with your index
finger, placed in radial positions around the
nipple. Watch for discharge appearing
through one of the duct openings on the
nipples surface. Note the color, consistency,
and quantity of any discharge and the exact
location where it appears.
Fig. 25

THE MALE BREAST

Gynecomastia is the enlargement of one or both breasts in a man. It often occurs
at puberty, occurs with aging, or is drug-related. Carcinoma of the breast affects
approximately 1000 men per year in the United State. The average age at the time of
diagnosis is 59 years. The most common clinical manifestation, occurring in 75% of
cases, is a painless, firm, subareolar mass or a mass in the upper outer quadrant of the
breast. As in women, breast carcinoma in men most commonly metastasizes to the
bone, lung, liver, pleura, lymph node, skin, and other visceral nodes.
Examination of the male breast may be brief but is sometimes important. Inspect
the nipple and areola for nodules, swelling, or ulceration. Palpate the areola and
breast tissue for nodules. If the breast appears enlarged, distinguish between the soft
fatty enlargement of obesity and the firm disc of glandular enlargement, called
gynecomastia.
Fig. 26. Gynecomastia

Examination.

BREAST SELF EXAMINATION (BSE)

Breast self-exam (BSE), or regularly self examining women breasts on their own,
can be an important way to find a breast cancer early, when it's more likely to be treated
successfully. Not every cancer can be found this way, but it is a critical step they can and
should take for theirself.
Pros and Contra
Over the years, there has been some debate over just how valuable BSE is in
detecting breast cancer early and increasing the likelihood of survival. For example, in
summer 2008, one study of nearly 400,000 women in Russia and China reported that
breast self-examination does not reduce breast cancer mortality and may even cause harm
by prompting unnecessary biopsies (removal and examination of suspicious tissue).
Because of the ongoing uncertainty raised by this and other studies, the American Cancer
Society has chosen to advise women that BSE is an optional screening tool.
Some women may feel a lot of anxiety in the day or two leading up to doing a
self-examination and while they are doing it. Because they are not sure what they are
looking for (even though doctors have explained it to them). Any find in breast changes
can induces more anxiety in women until physician consultation is obtained
Some organizations still believes that BSE is a useful and essential screening
strategy, especially when used in combination with regular physical exams by a doctor
and mammography. Often breast cancers are found by physical examination rather than
by mammography. Some organizations recommend that all women routinely perform
breast self-exams as part of their overall breast cancer screening strategy.
Evidence confirms that a large proportion of breast cancers are palpable and self
detected, that some breast cancers are mammographically invisible particularly in
younger women and women with dense breast tissue, that the components of effective
breast self-examination are now known and validated, that the skill can be learned and
that women who learn and practice proficient breast examination possess an advantage in
protecting their health and their lives.
Women should, however, be aware of any breast changes. It is possible that
increased breast awareness may have contributed to the decrease in mortality from breast
cancer that has been noted in some countries. Women should, therefore, be encouraged to
seek medical advice if they detect any change in their breasts that may be breast cancer.
Basic BSE Method
The best time to perform BSE is 7-10 days after your period. If you no longer
have periods, do BSE on the same day each month. Women who are pregnant, are
breastfeeding, or have breast implant should still do BSE. Use a consistant pattern to
examine your breast each month. Many healthcare professionals recommend using the
vertical (grid) pattern while lying down.
Use the flat surface of the three fingers to make overlapping, dime-size, circular
motions on the breast tissue. Apply light, medium, and firm pressure to examine all levels
of breast tissue.
Fig. 27. Vertical/Grid Pattern
Fig. 28. Circular Pattern
Fig. 29. Wedge Pattern
Source: Atkins, K. Breast Care. (adapted from http://www.HealthEdco.com )
Lying Supine Position

1. Lie down with a pillow under your right shoulder. Place your right arm behind
your head
2. Use the finger pads of the three middle fingers on your left hand to feel for lumps
in the right breast. The finger pads are the top third of each finger.
3. Press firmly enough to know how your breast feels. A firm ridge in the lower
curve of each breast is normal. If youre not sure how hard to press, talk with your
health care provider, or try to copy the way the doctor or nurse does it.
4. Press firmly on the breast in an up-and-down or strip pattern.You can also use a
circular or wedge pattern, but be sure to us the same pattern every time. Check the
entire breast area, and remember how your breast feels from month to month.
5. Repeat the examination on your left breast, using the finger pads of the right hand.
6. If you find any changes, see your doctor right away.
(see figure 30 and 31)
Fig 30 and 31. Lying Supine Position in BSE

Examination.

Standing Position
1. Repeat the examination of both breasts while standing, with one arm behind your
head. The upright position makes it easier to check the upper outer part of the
breasts (toward your armpit). This is where about half of breast cancers are found.
You may want to do the upright part of the BSE while you are in the shower. Your
soapy hands will make it easy to check how your breasts feel as they glide over
the wet skin.
2. For added safety, you might want to check your breasts by standing in front of a
mirror right after your BSE each month. See if there are any changes in the way
your breasts look, such as dimpling of the skin, changes in the nipple, redness, or
swelling.
3. If you find any changes, see your doctor right away.
(see figure 32 and 33)
Fig 32 and 33. Standing Position in BSE

Examination.
FEEDBACK FORM OF BREAST EXAMINATION

(Breast Examination by General Practitioner)
Name
: .........................................................................
Student No : ..........................................................................
No
Step
1. Introduction
2.
Sitting Position
3.
Preparation
4.
Arms at Sides
5.
Arms Over Head,

Hands Pressed Against
Hips, Leaning Forward
(if necessary)
6.
Axillary examinations
Positioning
7.
Axillary examinations
palpation
Aspects
Self introducing and greetings
The examiner explain to the patient about
the procedure
The examiner ask and help patient to the
sitting position, seated on the edge of the
examination table, facing the examiner.
The examiner wash the hands using
alcohol 70%, then put the gloves on.
The examiner should ask the women to
remove her gown to her waist
The examiner ask patients to put her arm
at sides. Examiner should inspect:
- The appearance of the skin (colour
changes, thickening)
- The size and symmetry of the breasts
- The contour of the breasts (masses,
dimpling, flattening)
- The characteristics of the nipples (size,
shape, direction)
The examiner ask the patient to raise her
arms over her head,
then press her hands against her hips,
and leaning forward (if necessary),
The students should inspect breast contour
(dimpling, retraction)
The examiner seated facing the examiner,
to examine the right axilla, the patients
right forearm is supported by the
examiners right hand
The tips of the fingers of the examiners
left hand start low in the right axilla, and,
as the patients right arm is drawn
medially, the examiner advances the left
Feedback
8.
Lie down positioning

and preparation
9.
Breast palpations
hand higher into the axilla.

using small, circular motion of the fingers
riding over the ribs
The examiner asks the patients to lie down
and is told that palpation of the breast is
next, their arms at their sides (small
breasts) or to place their hands behind
their head (larger breasts).
A pillow placed beneath the shoulder on
the side (if necessary)
The examiner may choose one of the
method: (9, 10, or 11)
Use the flat of the hand and the fingertips
(9 and 10)
Or use three middle fingers (the 2nd, 3rd,
and 4th fingers, keeping the fingers slightly
flexed) are held together and slightly
10. Spokes of a wheel
11. Concentric Circles

12. Vertical Strip
13. Examination of the

nipple
14. Examines for discharge
15. Describe the Findings
bowed to ensure contact with the

skin.using the pads and dimensized circle.
(11)
Start the palpation by moving outward
from the nipple to the 12 oclock position.
The examiner then should return to the
nipple and move along the 1 oclock
position and continue the palpation around
the breast
Starts at the nipple, moves from the nipple
in a continuous circular manner around
the breast
The breast is divided into eight or nine
vertical strips, each approximately one
finger-width wide,
to palpate a rectangular area extending
from the clavicle to the inframammary
fold or bra line, and from the midsternal
line to the posterior axillary line and well
into the axilla for the tail of the breast
Inspect for nipple retraction, fissures, and
scalling
Ask the women whether she would prefer
to do this part of the examination herself.
place each hand on either side of the
nipple and gently compress the nipple
Consistency, Tenderness, Nodules
(location, size, shape, consistency,
delimitation, Tenderness, mobility
16. Conclusion
The examiner explain the examination

result to the patient
Global Rating Scale for Professional Behavior

No
Skills
Scientific basis and
explanation
1.
Demonstrate confidence
during performing skills
in front of patient
2.
Ethics (Respect the

patient, demonstrate
local values and norms)
Building and
maintaining adequate
relationship with
patients during the
whole consultation
2.
Exploration on patient
problem and summarize
the problem
2
Below
expectation
1
Unexpected
2
Below
expectation
3
Meet
expectation
4
Exceeding
expectation
5
Excellent
4
Exceeding
expectation
5
Excellent
Dealing with one-self:

(student able to behave
professionally without showing
his/her anxiety, sadness and
worries)
Dealing with others:
his/her assumptions about
patient)
Global Rating Scale for Doctor-Patient Interaction

No
Skills
explanation
1.
Scale
1
Unexpected
Scale
3
Meet
expectation
Ability to build a good

relationship
(through active listening,
response properly, empathy,
interpersonal communication
and putting patient at ease)
Ability to explore patients
problem and summarize it
(through exploration, data
gathering, history taking, alloanamnesis, checking and
summarization)
Explanation:
Scale 1: Unable to demonstrate respect and norms + More than 80 % error
Scale 2: Below observers expectation (demonstrate minimal respect and norms + 60%-80% error)
Scale 3: Meet observers expectation (demonstrate minimal respect and norms + 40%-60% error)
Scale 4: Exceed observers expectation (demonstrate minimal respect and norms + 20%-40% error)
Scale 5: Excellent (demonstrate minimal respect and norms + less than 20% error)
Yogyakarta, ..
Instructor
()
FEEDBACK FORM FOR TEACHING BREAST SELF EXAMINATION (BSE)

(Teaching BSE to the patient)
Name
: .........................................................................
Student No : ..........................................................................
No
Step
1.
Introduction
2.
Aspects
3.
Timing
4.
Fingers positions,
movements and pressure
5.
Paterns
6.
Lying supine position
7.
Standing position
8.
Consult to physician
Aspects
Introducing Breast Self Examination
to a patient
Explaining Positive and negative
aspects of Brest Self Examination
Explaining time of Breast Self
Examination and the reason
Explaining to use the flat surface three
fingers to make overlapping, dimesize, circular motions on the breast
tissue. Apply light, medium, and firm
pressure to examine all levels of breast
tissue.
Explaining the paterns, recommended
vertical grid paterns,
Lie down with a pillow under your
right shoulder. Place your right arm
behind your head
Use the finger pads of the three middle
fingers on your left hand to feel for
lumps in the right breast. And vice
versa
Arm position behind your head,
Using soapy hand,
In front of mirror,
Look for any changes:
dimpling of the skin, changes in the
nipple, redness, or swelling.
If you find any changes
Global Rating Scale for Professional Behavior

No
Skills
explanation
Feedback
Scale
1
Unexpected
2
Below
expectation
3
Meet
expectation
4
Exceeding
expectation
5
Excellent
3.
Demonstrate confidence
during performing skills
in front of patient
4.
Ethics (Respect the

patient, demonstrate
local values and norms)
Dealing with one-self:

his/her anxiety, sadness and
worries)
Dealing with others:
his/her assumptions about
patient)
Global Rating Scale for Doctor-Patient Interaction

No
Skills
explanation
3.
Building and
maintaining adequate
relationship with
patients during the
whole consultation
4.
Exploration on patient
problem and summarize
the problem
Scale
1
Unexpected
2
Below
expectation
3
Meet
expectation
4
Exceeding
expectation
Ability to build a good

relationship
(through active listening,
response properly, empathy,
interpersonal communication
and putting patient at ease)
Ability to explore patients
problem and summarize it
(through exploration, data
gathering, history taking, alloanamnesis, checking and
summarization)
Explanation:
Scale 1: Unable to demonstrate respect and norms + More than 80 % error
Scale 2: Below observers expectation (demonstrate minimal respect and norms + 60%-80% error)
Scale 3: Meet observers expectation (demonstrate minimal respect and norms + 40%-60% error)
Scale 4: Exceed observers expectation (demonstrate minimal respect and norms + 20%-40% error)
Scale 5: Excellent (demonstrate minimal respect and norms + less than 20% error)
Yogyakarta, ..
Instructor
()
5
Excellent
REFERENCES
1. Bickley L.S. dan Szilagyi P.G. Bates Guide to Physical Examination and History
Taking. 9th edition. Lippicott Williams & Wilkins. 2007
2. Swartz, M.H. Textbook of Physical Examination : History and Examination. 4th
edition. W.B. Saunders Company. 2002
3. Atkins, K. Breast Care. (taken from http://www.HealthEdco.com )
4. Mann CV, Russell RCG, Williams NS (eds) edition Chapter 39. The Breast, In Baley
& Loves: Short Practice of Surgery, wenty-second, ELBS with Chapman & Hall,
London. 1995
Appendix 1
SEX MATURITY RATINGS IN GIRLS : BREASTS
Appendix 2
Safety Precaution of Breast Examination Tools
1. Before using the breast examination tool, make sure that you have cut your
finger nail.
2. Wash your hand, and use the gloves during the examination.
3. Do not mark using ink pen.
4. Use it carefully.
5. Follow the whole procedure and correct instruction.

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SKILLS TRAINING MANUAL BOOK

BASIC SURGICAL SKILLS

Assistant of Content Development Team for Skills Training

Educational Design Reviewed by

Level of Expected Ability

General physical examination including breasts

BSE review and

Figure 1. The Breast and Axillae

Fig. 4. Lymphatic drainage of the breast

Source: Swartz, M.H. Textbook of Physical Examination : History and

Common Breast Masses

30-90, most common

Retraction Sign Absent

Risk Factors for Breast Cancer

Menstrual History and Pregnancy. Early menarche, delayed menopause,and

Visible Signs of Breast Cancer

Edema of the skin

The Following Questions

Can you describe the pain?

What is the color of the discharge?

Is the discharge associated with nipple retraction? a breast

A change in the color or texture of the skin of the breast or

Do you take estrogen replacement therapy?

Fig. 11. Arms At Side

Arms Over Head; Hands Pressed Against Hips; Leaning Forward.

Dimpling or retraction of the breasts in

Occasionally, these signs may be

This position may reveal an asymmetry of

Fig. 14. Leaning Forward

Fig. 15 and 16. Technique for axillary examination

4th edition. W.B. Saunders Company. 2002

Fig. 17 & 18 . Spokes of a Wheel Method

4th edition. W.B. Saunders Company. 2002

B. Concentric Circles (Circular) Method

Fig. 19 & 20. Concentric Circles Method

4th edition. W.B. Saunders Company. 2002

C. Vertical Strip (Grid) Method

Fig. 21 and 22. Vertical Strip Method

Describe the Findings in Palpation

Consistency of the tissues. Normal consistency varies

Tenderness, as in premenstrual fullness

Nodules. Palpate carefully for any lump or mass that is

Fig. 23 & 24. Technique for nipple examination

Another methode to examine spontaneous

Source: Bickley L.S. dan Szilagyi P.G. Bates Guide

THE MALE BREAST

Fig. 26. Gynecomastia

Source: Swartz, M.H. Textbook of Physical Examination : History and

BREAST SELF EXAMINATION (BSE)

Fig. 27. Vertical/Grid Pattern

Fig. 28. Circular Pattern

Fig. 29. Wedge Pattern

Source: Atkins, K. Breast Care. (adapted from http://www.HealthEdco.com )

Lying Supine Position

Fig 30 and 31. Lying Supine Position in BSE

Source: Swartz, M.H. Textbook of Physical Examination : History and

Fig 32 and 33. Standing Position in BSE

FEEDBACK FORM OF BREAST EXAMINATION

Arms Over Head,

Lie down positioning

hand higher into the axilla.

10. Spokes of a wheel

11. Concentric Circles