Tuesday

Breast: History taking & clinical exam

this note is  for Medical students, physician reference :

  • Discharge, bleeding.
  • Tenderness (inflammatory, eg abscess).
  • Location: quadrants, proximity to nipple, unilateral vs. bilateral, 
  • Timing: spread of masses.
  • Timing: midcycle tenderness (fibrocystic change).
  • Currently breast feeding (mastitis).
CA risk factors
  • A History ALONE:
    • Age: older
    History: family, prior dz
    • Abortion
    • Late menopause
    • Obese
    • Nulliparity
    • Early menarche
Setup
  • Pt removes upper body clothing, in gown, sitting up.
  • Briefly describe examination to pt.
  • Pt. removes gown.
  • Pt. relaxes arms by side.
Inspect: whole breasts
  • Symmetry.
  • Swelling.
  • Visible masses.
Inspect: skin
  • Dimpling.
  • Peau d'orange (CA).
  • Skin retraction.
  • Veins: bilateral vs. unilateral (CA).
Inspect: nipples
  • Nipple position, inversion, retraction (fibrosis, CA, normal).
  • Red, bleeding (Paget's dz of nipple).
  • Discharge.
Inspect: maneuvers
  • Pt. raises arms above head. Look for:
    • Change in a mass's relative position.
    • Nipple or skin tethering.
  • Examine axillae while pt's arms are raised. 
  • Pt. pushes hands down on hips. Look for:
    • Dimpling.
    • Fixation.
  • Large breasts: pt. leans forward, hands on knees.
Palpate: nodes
  • Axillary nodes.
  • Supraclavicular nodes.
  • See Hemolymphoid Examination.
  • If exam normal so far, tell pt.
Palpate: quadrants
  • Pt. lies down.
  • Pt. places hands behind head.
  • Ask if any part tender before palpate (inflammatory).
  • If sores visible, wear gloves.
  • Use fingerpads of middle 3 fingers.
  • Press breast against chest wall by rolling fingers in small, circular motions.
  • Press lightly for superficial layers, medium pressure for middle layer, firmer pressure for deepest layers.
  • Start at sternoclavicular junction.
  • Move in overlapping vertical strips, until all 4 breast quadrants are covered.
  • See Examining A Mass Reference.
Palpate: axillary tails
  • Pt. places arms above head.
  • Palpate tail between fingers and thumb.
Palpate: nipples