BREAST EXAMINATION

Comprehensive Guide to Breast Examination

Breast examination is an essential clinical skill for detecting benign and malignant breast conditions early. A systematic approach ensures no findings are missed. This guide will walk you through general inspection, palpation, and special tests, ensuring a thorough examination.

1. General Considerations Before Examination

✅ Ensure patient privacy (use a chaperone if necessary).
✅ Obtain informed consent—explain the procedure clearly.
✅ Ensure proper positioning—patient should be seated for inspection and supine for palpation.
✅ Ask relevant history (breast pain, lumps, discharge, family history of breast cancer).
✅ Use the pads of your three middle fingers for palpation, not fingertips.

2. General Inspection

🔹 Position the patient sitting upright with arms at sides.
🔹 Observe for the following in both breasts:

  • Size & symmetry: Asymmetry can be normal, but sudden changes are concerning.

  • Skin changes: Redness, dimpling, ulceration, peau d’orange (seen in breast cancer).

  • Nipple changes: Retraction, scaling, discharge.

  • Swelling or visible masses.

Dynamic Inspection (Assessing for Subtle Abnormalities)

Ask the patient to:
✅ Raise arms overhead: Identifies skin tethering or retractions.
✅ Press hands against hips & push inward: Highlights dimpling from underlying mass.
✅ Lean forward: Helps assess symmetry & nipple retraction.

3. Palpation of the Breast

Patient Position:

  • Supine with ipsilateral arm behind the head to flatten the breast tissue.

  • Use three middle fingers with firm but gentle pressure in small circular motions.

Systematic Palpation Techniques

✅ Vertical Strip Pattern (Preferred) → Move fingers in parallel rows from clavicle to inframammary fold.
✅ Concentric Circles → Start from the nipple and move outward.
✅ Radial Spokes → Move from the nipple outward like spokes of a wheel.

🔹 Assess for:

  • Masses (Location, size, shape, consistency, mobility, tenderness).

  • Tenderness (suggests infection or cyst).

  • Skin tethering over a mass (suggests malignancy).

  • Nipple discharge (color, unilateral or bilateral).

4. Examination of the Axillary & Supraclavicular Lymph Nodes

✅ Position: Patient sits with arm relaxed at the side.
✅ Palpate using a rolling motion:

  • Axillary nodes: Central, lateral, anterior, posterior, and apical.

  • Supraclavicular & Infraclavicular nodes: Enlarged nodes are suspicious for malignancy.

🔹 Note: Hard, fixed, painless nodes suggest malignancy; tender nodes suggest infection.

5. Special Tests & Signs

🔹 Peau d’Orange (Skin Dimpling) → Edematous, thickened skin due to lymphatic obstruction (breast cancer).
🔹 Paget’s Disease of the Nipple → Scaly, eczematous nipple changes (suggestive of underlying carcinoma).
🔹 Milky Discharge (Galactorrhea) → May indicate hormonal imbalance (prolactinoma, medication side effects).
🔹 Bloody or Unilateral Discharge → Concerning for malignancy (ductal carcinoma).

6. Documentation of Findings

Use the clock-face method or quadrants to describe location:
✅ Upper Outer Quadrant (UOQ) → Most common site for breast cancer.
✅ Upper Inner Quadrant (UIQ)
✅ Lower Outer Quadrant (LOQ)
✅ Lower Inner Quadrant (LIQ)

🔹 Example Documentation:
"Firm, non-tender, immobile 2 cm mass in the upper outer quadrant of the right breast, with nipple retraction and no axillary lymphadenopathy."

7. Red Flags Suggestive of Breast Cancer

🚩 Hard, irregular, non-mobile lump.
🚩 Skin dimpling or peau d’orange.
🚩 Nipple retraction or inversion.
🚩 Bloody nipple discharge.
🚩 Enlarged, hard axillary nodes.

8. Tips to Stand Out in Clinical Practice

✅ Always correlate with history (family history, hormonal therapy, recent trauma).
✅ Reassure the patient throughout the exam—exams can be anxiety-inducing.
✅ Use a systematic approach every time to avoid missing abnormalities.
✅ Know when to order further tests (mammogram, ultrasound, biopsy).