Structure: Breast Examination

Casebank Combined
1

Take focused hx (2 min):

Follow same structure
(P1 – P2 – P3 P4 – MAFTOSA).
P1 (which one – what about other)
Most relevant Qs:

  1. Any lumps in breast?
    − Is it felt only during period? ( Fibro adenosis)
    − Is it not related to period? (Fibroadenoma)
  2. Any pain in breast?
    – Only during period? (Cyclic mastalgia )
    – Not related to period? (Abscess – mastitis)
  3. FLAWS ( dd benign from malignant)
  4. Trauma (fat necrosis)
  5. Nipple discharge (if + ve → TRAC)
  6. Family hx.
  7. HRT or OCP (medications)

EXAMINATION STEPS (4 MIN)

PPCCE

• Is it ok to examine your breast and check the lump you have?
• For the purpose of examination, I will be looking at your breast, touching
them for the lump and check L. Ns of your breast?
• I will ensure your privacy
• I will have a chaperon during the examination.
• I would like you to expose yourself from above waist, would that be alright with you?

INSPECTION
(sitting)

  1. Lap
    • Put your hands on your lap.
    • Check if breast and nipples are symmetrical.
  2. Hip
    • Put your hands on your hips and lean forward
    • To look for any visible masses
  3. Breast
    • Lift your 2 breasts with 2 fingers
    • To look for any fungal infection.
  4. Breast
    • Squeeze your nipples with 2 fingers.
    • Look for any discharge.
  5. Neck
    • Put your hands behind your neck
    • To check axillary and supraclavicular L.Ns.

PALPATION
(Lying 45 degree)

  • Any pain anywhere?
  • Temperature
    – With back of your hands
    – Compare both sides (inner with inner quadrant – outer with outer quadrant)
  • Tenderness
    – Look at ptn face
  • Deep palpation
    1. Around areola
      → with one finger
      → Do not touch nipples
    2. 4 Quadrants
      → Anti clock
      → If you feel the mass, I appreciate the mass + describe:
      − Site
      − Size
      − Attached to skin or underlying structures
      − Painful
      − Tender
    3. Axillary tail

LYMPH NODES (Standing )

  1. Stand infront of ptn AMA
    – Anterior
    – Medial
    – Apical
  2. Stand behind ptn and ask her to cross her arms together
    − Posterior
    − Lateral

After Examination
• Thank ptn
• Ask her to cover up.

Management (2 min)

  1. Refer urgent for breast clinic for triple assessment (in 2 wk)
  • Age 30 or more with unexplained lump in the breast with or without
    pain.
  • Age 30 or more, with unexplained lump in the Axilla
  • Age 50 or more with following symptoms in one nipple only- discharge, retraction, other changes of cancer
  • Skin changes that suggest breast cancer.
    a. They ‘ll examine you further.
    b. IF < 40 y → US
    c. IF > 40 Y → Mammogram then US
    d. FNAC → take tissue sample
  1. Senior.
  2. Investigations.
    a. CBC
    b. U & E
    c. Infection markers
  3. Symptomatic and lifestyle (ex : stop smoking)
  4. Safety netting.
    a. Wt loss.
    b. Lumps and bumps.
    c. Nipple discharge.
    d. Bleeding anywhere.
10 Likes
2

Hi this is amazing during my examination so I do running commentary about the negative findings or do I just examine the patient in silence

3

I have been told to make commentaries. “if you don’t say it, it means you don’t know it” that was what I was told.

1 Like
4

will we be askin the patient to squeeze their nipple or
lifting the breast?