Performing a Breast Examination
The aim of this section is to enable the student to undertake in a logical
sequence a competent breast examination demonstrating a sensitive and empathic
approach to the needs of the patient.
Consider the need for an interpreter if English is not the patient’s first
language. Using clear and simple terms understandable to the patient, introduce
yourself and explain the need to perform a breast examination. Discuss the procedure
with her and obtain her permission to proceed. Provide privacy for her to change
and provide suitable cover for her (gown or sheet). Ensure that the room is
warm and that there is adequate light to undertake the examination.
Observing the breasts with the patient in the upright position
This part of the examination is performed with the patient’s arms relaxed at
her sides. An extended exam may also include these positions:
- the patient places her arms above and behind her head
- the patient places her arms above and behind the head while she leans forwards
so that the breasts move off the chest wall
- the patient places her hands on her hips, pressing in firmly thereby contracting
the pectoralis major muscle to which the suspensory ligaments of the breast
are attached.
While the patient is in each of these positions, inspect each breast for symmetry
recognizing that the breast of the dominant hand is often slightly larger but
otherwise similar to its twin. Inspect for scars, asymmetry, differences in
contour, peau d'orange, dimpling, mass lesions, skin ulceration, skin
discoloration, nipple changes (retraction, inversion, ulceration, discharge,
eczema). Inspection in this manner may elicit dimpling due to contraction of
Astley Cooper's ligaments, and demonstrate asymmetry and associated subtle changes
in form. These aspects may be the only clinical clue of a carcinoma within the
breast.
Palpation of the breasts
Have the patient recline. Commence the examination with the unaffected side
to establish the normal texture and nodularity. If there is no “affected” side
then the examination can commence with either breast. Ask her to place her hand
(of the unaffected side) with the palm resting under her head and the other
arm lying by her side. Make sure that her chest is rotated so that breast rests
on the chest wall evenly. Palpate the breast with the hand flat and with the
pulps of the outstretched fingers, not pinching with the tips of the fingers.
Palpate the breast in strips vertically and horizontally, to include all quadrants
including retro-areolar regions and axillary tail. If a lump is found, identify
the features of the lump, test for deep fixation of the lump by contracting
pectoralis major, and test for overlying skin or nipple attachment. Now ask
the patient to reverse the position and repeat the examination with the other
breast.
Examine the axilla for lymph nodes (pectoral, posterior, lateral, central,
apical) and examine for the supraclavicular and infraclavicular lymph nodes.
Small soft lymph nodes are often palpable normally, particularly in thin patients
and may be up to 1 centimetre in diameter. A general examination may then be
undertaken, in particular of the head and neck, chest, back and abdomen.
When you have completed your examination ask the patient to dress. Document
your findings and discuss these with the patient.
References:
Details of history and examination of the breast are given in
Toouli James, Chris Russell, Peter Devitt, Celia Ingham Clark (2000) Integrated
Basic Surgical Sciences (London: Arnold). Pages 355-357.
Websites:
1. NHMRC National Breast Cancer Centre
This centre is funded by the Department of Health and Aged Care. It has special
sections on early detection, screening and counselling skills specific to this
topic. The web address is:
http://www.nbcc.org.au/default.htm
2. NHMRC Websites for breast cancer:
http://www.nbcc.org.au/pages/info.htm
http://www.nbcc.org.au/pages/info/resource/nbccpubs/nbccpubs.htm
3. Information on breast self examination
http://www.qldcancer.com.au/Cancer_Info_and_Services/PED/BreastSelfExamination.html
4. Cochrane Breast Cancer Group http://www.cochrane.org/
select Abstracts of Cochrane Reviews;
select Cochrane Breast Cancer Group.
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