Breast examination

By Dr. Sanmook
 When should someone have a clinical breast
examination?

● Every 1-3 yrs between ages 20 to 39 yrs

● After 40 yrs -> yearly & mammograms every 1-2 yrs (Nb frequency varies
with family history.)
● Complaints such as breast pain, skin changes, nipple discharge, lumps,
gross changes in size & shape etc
● Wash hands
● Introduce yourself and verify patient
● Explain the exam
● Explain the need for a chaperone
● Ensure patient understands and consents
 ● Patient seated upright and side of bed

Adequate exposure - undress down to waist ( allow privacy to undress)

If patient primary complaint is a lump ask about location, ask if any pain?
 Inspection

● Hands on thighs and relaxed.

Inspect for :

1. Scars
2. Asymmetry
3. Masses
4. Nipple abnormalities( such as inversion & discharge)
5. Skin changes ( erythema, peau d’orange, scaling & puckering)
https://www.slideshare.net/JoshuaSimon16/breast-lumps-dr-tuse https://www.dummies.com/health/diseases/cancer/look-breast-self-examination/
 ● Repeat inspection with patient pressing their hands on hips ( contracting
pectoralis muscles)

Is mass is visible -> does it move with contraction of muscle? - suggest tethering
to underlying tissue.

Accentuated puckering -if invading suspensory ligament of breast is also tethered

by pectoralis muscle
https://www.google.com/amp/s/www.mskcc.org/cancer-care/types/breast/anatomy-breast%3famp
 ● Inspect with arms on head while leaning forward

Observe for asymmetry, puckering or skin dimpling( may be exaggerated)

 Palpation
● Patient supine, head of bed @ 45°

Examine asymptomatic breast first !

Patient should place their hand behind their head on the side being examined->
adequate exposure.

Different techniques :(but ensure examine all parts)

1. Clock face method

2. Spiral method
3. Quadrant method
Use the flats of your 3 middle fingers to compress the breast tissue against the
chest wall,as you feel for masses.

If a mass is detected note:

1. Location
2. Size
3. Shape
4. Consistency
5. Mobility
6. Fluctuance
7. Overlying skin changes
NB ensure you examine the axillary tail( projection of tissue in the upper outer
quadrant of breast extending to axilla)

Cancer can be detected here.

https://stanfordmedicine25.stanford.edu/the25/BreastExam.html
https://www.slideshare.net/yuyuricci/beni
gn-and-malignant-breast-diseases
 Nipple areolar complex
● Use flats of middle 3 fingers to compress the areolar tissue towards the nipple
-> look for discharge.

If history of discharge;

Hold nipple between finger and thumb to express ( discharge maybe milky, watery
and bloody or purulent)

Assess Colour/ Consistency /Volume

Elevate the breast and inspect.

Lymph node examination-

● Axillary
● Cervical
● Supraclavicular
● Infraclavicular
 Axillary lymph node examination
Patient sitting upright

Any pain in either shoulder before exam?

Inspect axilla - scars, masses or skin

Hold patient right arm with your right hand (slight abduction at 45 deg) so axillary
muscle is relaxed

Use left hand to palpate ( reverse with left)

In axilla palpate anterior ,posterior, medial and lateral and apical group of lymph
nodes.
https://teachmeanatomy.info/upper-
limb/vessels/lymphatics/
Remember to inspect: ( from behind)

● Cervical
● Supraclavicular
● Infraclavicular
Common causes of axillary
lymphadenopathy?
Infections of upper limb

Infections to pectoral region and breast

Metastasis to breast cancer

 Further Investigations
● Mammography - pts > 35 yrs
● ultrasound - pts < 35 yrs
● biopsy
References
https://www.dummies.com/health/diseases/cancer/look-breast-self-examination/

https://www.slideshare.net/JoshuaSimon16/breast-lumps-dr-tuse

https://www.google.com/amp/s/www.mskcc.org/cancer-care/types/breast/anatomy-breast%3famp

https://stanfordmedicine25.stanford.edu/the25/BreastExam.html

https://www.slideshare.net/yuyuricci/benign-and-malignant-breast-diseases
https://teachmeanatomy.info/upper-limb/vessels/lymphatics/

https://geekymedics.com/breast-examination-osce-guide/

https://www.ncbi.nlm.nih.gov/books/NBK459179/#:~:text=Complaints%20of%20breast%20pain%2C%20skin,clinic
al%20breast%20exam%5B5%5D.