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Breast Exam
- 2. 11/14/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 2
Examination of the breast II
- 3. 11/14/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 3
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
Breast
size
symmetry
shape of breast
skin colour
lumps
skin tethering
prominent veins or oedema
of the skin with dimpling like
orange skin (peau d’orange)
Nipples
everted, flat, or inverted
(note if recent change or
longstanding
cracking or ‘eczema’
gross deviation of the nipple
bleeding or discharge
Areola: observe for
abnormal reddening
thickening
The patient should be undressed to the waist and
seated with arms by side
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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
palpation.Pictures from the American association of plastic surgeons
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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
segment is overlappedPictures from the American association of plastic surgeons
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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)
It is often best to record
findings graphically
Record presence of any
nodes in the axilla,
supraclavicular or
infraclavicular areas
UIQ
LIQ
UOQ
LOQ
AT
LEFT
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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