SKILL 6 LABORATORY PRACTICE MODULE

BLOCK : REPRODUCTIVE SYSTEM

TOPIC : BREAST AND AXILLA EXAMINATION

Specific Learning Objectives :

 Describe the difference between benign and malignant breast disease, according
to history taking and physical examination.
 Describe and perform breast examination procedure
 Informed consent to the patient about the physical examination and the
findings.

Anatomic Review

History Taking of Breast Disease

A. Chief Complaint
 Most women will complaint lump or pain in the breast
 Others: change in size, tenderness, discharge from nipple
 Not all symptoms are malignant; breast cancer is extremely rare before age of
25, and the incidence is high from 40 to 50
 Not only female, but less than 1% are male
Non-malignant Breast Disease
 Fibroadenoma
 Most common benign disease
 Occur almost exclusively in the reproductive years
  Young women
 Breast Infection
 Occur during pregnancy or lactation
 Fat necrosis
 Rare, occur in older age; appears long after trauma
 Others: lipoma, mammary duct ectasia
 Benign Phyllodes tumor
Malignant Breast Disease
 Non invasive carcinoma
 Non invasive ductal carcinoma
 Lobular carcinoma in situ
 Invasive carcinoma
 Invasive ductal carcinoma
 Special types
Paget’s disease

Signs and Symptoms

PAIN
 Painful LUMP
 Independent to menstrual cycle: may occur in carcinoma (rare), infection
(abscess)
 Cyclical nodularity: fibroadenosis
 Pain and Tenderness but NO LUMP
 Varying with mestrual cycle: physiological (Cyclical mastalgia, including
perimenstrual tension)
 Pregnancy mastitis
 Non-cyclical mastalgia
LUMP in the Breast
(Painless lump)
 Hard:
 Mobile, Solid, Cystic, smooth surface: most likely benign.
 Ill-defined margin, tethering to superficial or deep structure: suggest
carcinoma
 Firm, poorly defined lump, lumpiness
 Suggest benign
 Soft
 Usually benign (lipoma)
Changes in Breast SIZE
Pregnancy
Benign hypertrophy
Giant fibroadenoma
Phyllodes tumor
Carcinoma
SKIN changes
 Dimpling: highly suggestive carcinoma
 Visible lump: cyst, carcinoma, phyllodes
 Peau d’orange: Pathognomonic carcinoma
 Redness: Usually infection
 Ulceration: neglected carcinoma

NIPPLE disorders
 Recent inversion: fibrosing underlying lesion; carcinoma
 Eczema: Paget’s disease
 Nipple discharge
 Milky: pregnancy or hyperprolactinemia
 Clear: Physiological
 Green: Perimenopausal, duct ectasia
 Bloody: possible carcinoma or intraductal papilloma
HistoryTaking
A. Chief Complaint
1. Greet the patient and introduce yourself, develop a warm and trustful
relation
2. Politely ask: patient identity and complete the general information:
 Name
 Age
 Sex
 Occupation
 Marriage status
 Number of children
3. Ask the reason why the patient come to the clinic
4. Ask for the following:
 Lump: since when, progressivity, pain
 Nipple discharge: spontaneously, color
  Risk factors
 Other lumps
 Signs of metastases to lungs, bones, liver,brain

Risk Factors of Malignancy

 AGE
 Age of first Childbirth / first labour (> 30 y.o)
 No Lactation
 Menstruation:
 Menarche: the younger the higher the risk (<12 y.o)
 Cycle: regular or iregular
 Menopause: the older the higher the risk (> 55 y.o)
 Hormonal medication, family planning
 Family history / 1st degree family with breast cancer or other cancer

Sign of metastases
 Bone pain, pathological fractures (vertebrae, ribs, pelvis, femur)
 Epigastric fullness, abdominal mass, jaundice (liver metastasis)
 Cough, dyspnea (lung)
 Breathlessness (pleura: pleural effusion)
Severe headache, epilepsy (brain)
Past medical history
 Previous breast operation
 Irradiation on the chest due to other reasons

B. Informed Consent for Breast Examination

 Explain the examination procedure
 Explain expectations of examination
 Proceed to breast examination only after explaining the procedure and the
patient agrees to undergo the examination
LEARNING GUIDE
History Taking

Basmalah

A Chief complaint

1 Greet the patient and introduce yourself , develop a warm and

trustful relation
2 Politely ask : Patient identity and complete the general information:
 Name,
 age,
 sex,
 occupation,
 marriage status,
 number of children
3 Ask the reason why the patient come to the clinic

4 Ask for the followings:

 Lump : since when, progressivity, pain
 Nipple discharge : spontaneously, colour
 Risk factors
 Other lumps
 Signs of metastases to Lungs, bones, liver

5. Past medical history

 Previous Breast operation
 Irradiation on the chest due to other reasons

B Informed consent for Breast Examination

6  Explain the examination procedure
 Explain expectations of examination
 Proceed to breast examination only after explaining the
procedure and the patient agrees to undergo the
examination.
C Getting ready
7.  Check the environment whether it is good enough for the
privacy of the patient
 Is there enough lighting?
 Ask the patient to expose his/her upper body
Handwashing

D Physical examination
8. General Status
 Height ,
 weight
 Vital signs measurements
 Head to toe examination

9. Local Status
 Inspection of the breast area
 Ask for the patient to sit with hand at the side, inspect the
skin texture, thickening, discoloration, retraction dimpling,
nipple retraction, asymmetry of the breast contour,
ulceration
 Ask the patient to raise the arms above her head and inspect
it once again like mentioned above
 Ask the patient to put her hand against her hips and inspect
once again like mentioned above
10 Ask the patient to lie down with a pillow under a shoulder and put
her hand above her forehead

Use the finger pads of 2nd, 3rd, and 4th with the vertical strip
pattern systematically and gently begin from midaxillary line (tail of
the breast) : Palpate lateral portion until reach midclavicular line
(nipple) as start point of the medial part

Ask the patient to move her hand from the forehead to shoulder
until the elbow at the level of shoulder

Use the finger pads of 2nd, 3rd, and 4th with the vertical strip
pattern systematically begin from the nipple of the breast to
midsternal line

If you find a lump, identify the location, number, size, shape,

consistency

Identify surface, mobility, edge/border, tenderness, and distance

from the nipple
11 Palpate the areola gently and look for nipple discharge by pinch it
gently
12 Ask the patient to sit down, and palpate the axilla by using your right
hand for the left axilla and also the same procedure for the right
axilla using your left hand
Palpate pectoral lymph node
 Palpate subscapular lymph node
Examine of supra and infra clavicular lymph node
Handwashing
13 Draw a conclusion of examination result
State the patient condition in the conclusion
14 Hamdalah

BE 2