examination of the female breast

flow of event

1. GIEP
2. positioning of patient
3. inspection of chest
4. palpation of the breast
5. palpation of the lymph nodes

first of all -

notify the patient the existence of a cheperone.

ask for consent, in a clear, well-understood language. state why and how you are conducting this physical exam.

Ask the patient to sit upright on a well-illuminated chair or side of a bed, undressed to the waist and with the hands resting on the thighs, so that the pectoral muscles are relaxed

Face the patient and look at the breasts for asymmetry, local swelling or changes in the skin or nipples. Ask the patient to press her hands firmly on her hips - this contracts the pectoral muscles - and repeat the inspection.

Inspect the Breasts

Inspection is first accomplished with the patient's arms at her side. Tell the patient, "I am inspecting the breasts for any changes in the skin, contour, or symmetry." The breasts are inspected for size, shape, symmetry, contour, color, and edema. The nipples are inspected as to size, shape, inversion, eversion, or discharge. The nipples should be symmetrical. Is any abnormal bulging present?

The skin of the breast is observed for edema. Edema of the skin of the breast that overlies a malignancy may show as peau d'orange.

Is erythema present? Erythema is associated with infection and with inflammatory carcinoma of the breast. The scar above the areola is from a previous biopsy of a benign breast mass.

Is dimpling present? The examiner must inspect the breasts for the presence of retraction phenomena. Dimpling is a sign of retraction phenomena that are due to an underlying neoplasm and its fibrotic response. Skin retraction is commonly associated with malignancy that causes an abnormal traction on Cooper's ligaments. The shortening of the larger mammary ducts by cancer produces flattening or inversion of the nipple. A change in the position of the nipple is important because many women have a congenitally inverted nipple on one or both sides.

Is there a red, scaling, crusting plaque around one nipple, areola, or surrounding skin? Paget's disease of the breast is a surface manifestation invariably associated with an underlying invasive or intraductal carcinoma. The lesion appears eczematous, but unlike eczema, it is unilateral. The skin may also weep and be eroded. A much less common form is extramammary Paget's disease, which is seen around the anus or genitalia and is usually associated with malignant disease of the adnexa, bowel, or genitourinary tract.

Ask her to raise her arms above her head to stretch the pectoral muscles and the skin over the breast, and finally to lean forward so that the breasts become pendulous. These actions expose the whole breast and exacerbate skin dimpling.

A change in the color or texture of the skin of the breast or areola is an important symptom of breast carcinoma. The presence of dimpling, puckering, or scaliness warrants further investigation. The presence of unusually prominent pores, indicative of edema of the skin, is an important sign of malignancy.

This clinical sign is called peau d'orange because of its orange-peel appearance. During the early stages of breast carcinoma, the lymphatics of the breast are dilated and contain occasional emboli of carcinoma cells. Limited peau d'orange over the lower half of the areola is present. As the disease progresses, more lymphatics become filled with carcinoma cells that block them, creating more generalized edema.

Palpation

The woman is asked to lie down and is told that palpation of the breast is next. The examiner stands at the right side of the patient's bed. Although the examiner can usually palpate each breast from the patient's right side, it is often better with large-breasted women to examine the left breast from the left side.

The breast is best palpated by allowing it to lie evenly distributed over the chest wall. Small-breasted women may lie with their arms at their sides; larger-breasted women should be instructed to place their hands behind their head. A pillow placed beneath the shoulder on the side being examined facilitates the examination.

With your hand held flat to the skin, palpate the breast tissue using the palmar surface of your middle three fingers and compress the breast tissue firmly against the chest wall.

Consider the breast as the face of a clock and examine each hour of the clock from the outside towards the nipple, including under the nipple. Compare the texture of one breast with that of the other. Examine all the breast tissue. Remember that the breast extends from the clavicle to the upper abdomen and the midline to the anterior border of latissimus dorsi (posterior axillary fold). Define the characteristics of any mass.

To determine if a mass is fixed to underlying tissue, ask the patient to place her hands on her hips. Hold the tumour between your thumb and forefinger and ask the patient to alternately contract and relax the pectoral muscles by pushing into her hips. Tethering to the pectoral fascia is where the tumour is solid with the chest wall when the pectoral muscle is contracted, but separate when it is relaxed. Infiltration occurs where the tumour is fixed to chest wall when the pectoral muscle is relaxed and contracted

Describe the Findings

If a mass is palpated, the following characteristics should be described: The size of the mass in centimeters and its position. The shape of the mass. The delimitation, referring to the borders of the mass. Is it well delimited, as with a cyst? Are the edges diffuse, as with a carcinoma? The consistency, describing the "hardness" of the mass. A carcinoma is often stony hard. A cyst has some elastic qualities. The mobility of the lesion. Is the lesion movable in the tissue that surrounds it? Benign tumors and cysts are freely mobile. Carcinomas are usually fixed to the skin, underlying muscle, or chest wall.

Examine the axillary tail between your finger and thumb as it extends towards the axilla.

Examination of the nipple concludes the examination of the breast. Inspect for nipple retraction, fissures, and scaling. To examine for discharge, place each hand on either side of the nipple and gently compress the nipple, noting the character of any discharge.

Ask the woman whether she would prefer to do this part of the examination herself

To palpate the nipple, hold it gently between index finger and thumb and try to express any discharge. Massage the breast towards the nipple to uncover any discharge.

Note the colour and consistency of any discharge along with the number and position of the affected ducts. Test any nipple discharge for blood using urine-testing sticks.

Nipple discharge is not a common symptom, but it should always raise the suspicion of breast disease, especially if the discharge occurs spontaneously. Any patient who describes a nipple discharge should be asked the following questions:

• "What is the color of the discharge?"
• "Do you have a discharge from both breasts?"
• "When did you first notice the discharge?"
• "Is the discharge related to your menstrual cycle?"
• "When was your last menstrual cycle?"
• "Is the discharge associated with nipple retraction? a breast mass? breast tenderness?"
• "Do you have headaches?"
• "Are you taking any medications?"
• "Are you using oral contraceptives?"

The most common types of discharge are serous and bloody. A serous discharge is thin and watery and may appear as a yellowish stain on the patient's garments. This commonly results from an intraductal papilloma in one of the large subareolar ducts. Women taking oral contraceptives may complain of bilateral serous discharge. A serous discharge can also occur in women with breast carcinoma

A bloody discharge is associated with an intraductal papilloma, which is common among pregnant and menstruating women. It may, however, be associated with a malignant intraductal papillary carcinoma. The presence of any nipple discharge is more important than its character because both types of discharge are associated with benign or malignant disease.

A milky discharge is usually milk. It is common for women to continue to secrete milk for a few months after they stop nursing. In rare instances, the secretion may continue for a year. Persistent lactation, also known asgalactorrhea, can be a result of massive hemorrhage occurring during childbirth and producing pituitary necrosis. Abnormal lactation may also result from a pituitary tumor that interferes with the normal hypothalamic-pituitary feedback loop or from the use of certain tranquilizing medications. Mechanical stimulation or suckling may produce physiologic stimulation.

Palpate the regional lymph nodes, including the supraclavicular group. Ask the patient to sit, facing you, with her shoulder relaxed so you are supporting the full weight of her arm at the wrist with your opposite hand. Place the flat of your other hand high into the axilla then move it upwards over the chest to the apex. This can be uncomfortable for patients so warn them and check for any discomfort. Compress the contents of the axilla against the chest wall. Assess the size, consistency and fixation of any palpable masses.

Examine the supraclavicular fossa.

First look for any visual abnormality then palpate the neck from behind and systematically review all cervical lymphatic chains.

During self-examination, a patient may discover a breast mass. Ask the following questions: "When did you first notice the lump?" "Have you noticed that the mass changes in size during your menstrual periods?" "Is the mass tender?" "Have you ever noticed a mass in your breast before?" "Have you noticed any skin changes on the breast?" "Have you had any recent injury to the breast?" "Is there any nipple discharge? nipple retraction?" "Do you have breast implants?" If yes, "What are they made of?"