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examination skills. This breast examination OSCE guide provides a clear step-by-step approach to examining the breast,
with an included video demonstration.
Introduction
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Briefly explain what the examination will involve using patient-friendly language: “Today I’ve been asked to perform a
breast examination. The examination will involve me first inspecting the breasts, then placing a hand on the breasts to
assess the breast tissue. Finally, I’ll examine the glands of your neck and armpit.”
Explain the need for a chaperone: “One of the female ward staff members will be present throughout the examination,
acting as a chaperone, would that be ok?”
Check if the patient understands everything you’ve said and allow time for questions: “Does everything I’ve said make
sense? Do you feel you understand what the examination will involve? Do you have any questions?”
Gain consent to proceed with the examination: “Are you happy for me to carry out the breast examination?”
Position the patient sitting upright on the side of the bed.
Ask the patient to undress down to the waist to adequately expose their breasts for the examination. Provide the patient with
privacy to get undressed and offer a blanket to allow exposure only when required.
If the patient has presented due to concerns about a lump, ask about its location. This can be helpful during initial inspection
and when palpating the breasts as you should always begin palpation on the asymptomatic breast.
Ask the patient if they have any pain before proceeding with the clinical examination.
Inspection
With the patient sitting on the side of the bed ask them to place their hands on their thighs to relax the pectoral muscles.
Inspect the breasts looking for:
Scars: these may indicate previous breast surgery such as lumpectomy (small scar) or mastectomy (large diagonal scar).
Asymmetry: this can be helpful in identifying abnormalities via comparison, however, it should be noted that breast
asymmetry is a normal feature in most women.
Masses: note any visible lumps that will require further assessment.
Nipple abnormalities: these can include nipple inversion and discharge.
Skin changes: including scaling, erythema, puckering and peau d’orange.
Nipple abnormalities
Nipple inversion is a normal finding in a significant proportion of women (e.g. congenital or weight-loss associated nipple
inversion). However, if nipple inversion develops without a clear precipitant, the possibility of underlying pathology should
be considered. Possible pathological causes of nipple inversion include breast cancer, breast abscess, mammary duct ectasia
and mastitis.
Nipple discharge is benign is most cases (e.g. pregnancy, breast-feeding) however less commonly it can be associated with
mastitis or underlying breast cancer (rare).
Axillary tail
The axillary tail is a projection of breast tissue that begins in the upper outer quadrant of the breast and extends into the
axilla. The majority of breast cancers develop in the upper outer quadrant so it’s essential this area is examined thoroughly.
Nipple-areolar complex
Use the flats of your middle three fingers to compress the areolar tissue towards the nipple as you inspect for any nipple
discharge.
If there is a history of nipple discharge, but none is visible, ask the patient to attempt to express discharge from the nipple (if
they are comfortable to do so) and assess the characteristics of the discharge:
Colour (e.g. blood-stained, green, yellow)
Consistency (e.g. thick, watery)
Volume
Nipple discharge
Milky discharge: normal during pregnancy and when breastfeeding (bilateral). Galactorrhoea (nonpuerperal lactation) is
pathological and caused by the presence of a prolactinoma.
Purulent discharge: thick yellow, green or brown discharge with an offensive smell. Possible causes include mastitis and
central breast abscess.
Watery and bloody discharge: several possible causes however ductal carcinoma in situ is the most important diagnosis to
consider.
Lymph nodes
Palpate the regional lymph nodes which are responsible for lymphatic drainage of the breast to identify evidence of breast
cancer metastases. Enlarged, hard, irregular lymph nodes are suggestive of metastatic spread.
Example summary
“Today I examined Mrs Smith, a 64-year-old female. On general inspection, the patient appeared comfortable at rest and
there were no objects or medical equipment around the bed of relevance.”
“Closer inspection of the chest did not reveal any scars or breast abnormalities.”
“Palpation of the breast did not reveal any masses and there was no regional lymphadenopathy.”
“In summary, these findings are consistent with a normal breast examination.”
“For completeness, I would like to perform the following further assessments and investigations.”