Examination of the Breast

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 Examination of the breast II

11/14/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 2

 General
 All examiners should normally be chaperoned
 The texture of normal breast tissue varies from
smooth to granular
 Texture may also vary with the menstrual cycle and
during pregnancy
 Nodularity and tenderness often increase towards
the end of the cycle and during menstruation
 Breast tissue is usually symmetrical so always
examine both and compare one to the other
 This examination could be performed on either
gender

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 Inspection
 The patient should be undressed to the waist and
seated with arms by side
 Breast  Nipples
 size  everted, flat, or inverted
(note if recent change or
 symmetry
longstanding
 shape of breast
 cracking or ‘eczema’
 skin colour
 gross deviation of the nipple
 lumps
 bleeding or discharge
 skin tethering
 Areola: observe for
 prominent veins or oedema
of the skin with dimpling like  abnormal reddening
orange skin (peau d’orange)  thickening

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 Inspection II
 Ask the patient to raise her arms above
her head (this is particularly important for
inspection of the axilla and axillary tail)
 Ask the patient to place hands on hips
and to apply downward pressure to the
hips whilst leaning forward slightly.
 An inspection of the breasts should also
be made once the patient is lying flat, as
abnormalities may become more
apparent when the tissue falls against
anterior chest wall

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 Inspection III
 These positions will:

 Stretch the breast tissue and overlying skin

 Exaggerate abnormalities of contour and skin
 Muscle tethering may be apparent

 In health women may have some slight asymmetry

of the breast and nipples

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 Breast Palpation I
 Patient lies on the couch
 When possible lying flat with
one pillow behind the head
 arms by her sides or with her
hand(s) behind her head
 Get on level with the patient (thus
avoiding pushing into the breast
tissue and causing the patient
discomfort)
 Palpate using palmar surface of
middle three fingers
 Use a rotary motion to gently
press the breast tissue against
the chest wall
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 Breast palpation II
 Examine each breast systematically covering the whole
cone of breast tissue using one of the following methods:
zig zag, concentric, or radial paths

 A systematic, methodical examination of all the breast

tissue (covering the four quadrants, axillary tail and
areola/nipple) ensures that small lesions are not missed
 With large or pendulous breasts, use one hand to steady
the breast on lower border whilst palpating with other
 Breast tissue should be palpated against the chest wall

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 Palpation of the breast

Breast
Mammary gland
Areola

Nipple

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 Systems of breast palpation I
 The examiner zigzags up
and down the breast
ensuring all tissue is
palpated.
 This method was the
preferred method for self
examination and
 It is preferred by some
clinicians as the breast
tissue remains in contact
with the chest wall during
Pictures from the American association of plastic surgeons
palpation.
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 Systems of breast palpation II
 The breast tissue is
examined using a
concentric circular
approach
 The examiner starts
at the periphery and
ends at the areola
and nipple
Pictures from the American association of plastic surgeons

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 Systems of breast palpation III
 The examiner divides the
breasts into a series of
segments
 The quadrants are
examined methodically in
turn from periphery
towards nipple
 The examiner traces a
pattern similar to a clock
face ensuring each
Pictures from the American association of plastic surgeons
segment is overlapped
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 Breast Palpation II - the axillary tail
 To examine the axillary tail of
Spence, ask the patient to rest her
arms above her head
 Feel the tail between thumb and
fingers as it extends from the
upper outer quadrant towards the
axilla
 If you feel a breast lump examine
the mass between your fingers
 Unlike fat the breast has distinctly
lobular texture which may be
tender to palpation Pictures from the American association of plastic surgeons

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Breast palpation III - the nipple and areola
 To examine nipple; hold the areola behind it
between thumb and fingers
 Gently compress, attempting to express any
discharge
 Note colour of any discharge and send
samples for cytology and microbiology
 On completion cover the breasts or offer the
patient the opportunity to put their bra back
on, either after or before examining the axilla

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 Examination of axilla 1
 With the patient sitting
facing the examiner
 The patient’s arm is
raised and supported
 The slightly cupped
fingers of the
examiners opposite
hand are inserted into
the apex of the axilla

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 Examination of axilla 2
 The patient’s forearm is rested
across the examiner’s forearm
 The examiner feels for each
group of lymph nodes, whilst
steadying the shoulder with
the other hand
 Apical
 anterior (posterior surface of
anterior axillary fold)
 medial (on the chest wall)
 lateral (against the humerus)
 posterior (anterior surface of
posterior axillary fold)
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 Examination of axilla 3
 An alternative is to ask the
patient to rest their hand on
the examiner’s shoulder
 The examiner then
methodically feels for each
group of nodes, whilst
steadying the shoulder with
the other hand
 Also examine the
supraclavicular and
infraclavicular areas for
nodes
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 Record findings
 Record any abnormalities
of the breast
 Identify which quadrant and
which breast (e.g. right
upper outer quadrant)
LEFT  It is often best to record
findings graphically
AT  Record presence of any
nodes in the axilla,
UIQ UOQ
supraclavicular or
LIQ LOQ infraclavicular areas

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 Recording your findings
 Don’t forget when recording your findings
 Patient identifier, date (and time), signature and
name
 When documenting the size, position and
shape of a swelling, a diagram may often be
useful.
 During some examinations you can still note
and record: size, position, shape, consistency,
surface and mobility. This must be done if a
swelling is detected
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