Introduce yourself, confirm the patient's name and date of birth. Briefly explain the purpose of the procedure and degree of exposure required. The patient should be undressed from the waist upwards, with the removal of any undergarments. Obtain consent and proceed to wash hands. For this examination, it is particularly important to have a chaperone.
Ask the patient if they are in any pain and are comfortable.
Commence the examination by requesting the patient to sit on the edge of the bed, completely exposed from the waist up. Begin inspection with the patient’s hands on their thighs to relax the pectoral muscles. Facing the patient, note if there is any:
Asymmetry (including shape and size of breasts).
Local swelling or lumps (including visible lymphadenopathy).
Skin changes (including erythema, rashes, scaling, puckering and peau d’orange).
Nipple changes (including inversion, symmetry and discharge).
Hands on hips
Repeat general inspection with the patient pressing their hands firmly onto their hips in order to contract the pectoralis muscles and accentuate any puckering, which may be due to infiltrative masses fixed to the underlying muscle.
Arm behind head
Finally, complete inspection of the patient with their arms raised behind their head and then with the patient leaning forward to expose the whole breast, exaggerating any asymmetry.
If the examination is preceded by a brief history-taking period, use the information ascertained to focus the inspection process, comparing the ‘pathological’ breast with the normal breast. For example, in a patient who is post-partum, breast feeding and febrile, be wary of a unilateral erythematous lump, with pain elicited on movement - this clinical picture would be suggestive of a breast abscess.
Erythema appears as a superficial reddening of the skin due to local inflammation. This is often secondary to infection, trauma or malignancy triggering cutaneous vasodilatation.
Scaling with pruritis and lichenification (hardening) of the nipple and/or areola is pathognomonic of Paget’s disease of the breast. This can be seen in ductal carcinoma in situ or invasive breast carcinoma.
Puckering, also described as dimpling, occurs due to neoplastic invasion of the suspensory (Cooper’s) ligaments, which normally provide the breast tissue with structural integrity. The malignant fibrosis and contraction of these ligaments pulls the overlying skin inwards.
Peau d’orange is breast oedema associated with an inflammatory cancer or infection. It is due to obstruction of dermal lymphatics and extensive axillary involvement, resulting in skin swelling between the hair follicles - thus resulting in an ‘orange peel’ dimpled appearance. Accompanying redness, tenderness and warmth may be apparent.
Nipple inversion, can be normal, due to significant weight loss or, if recent onset and in the presence of other features, indicative of pathologies including mammary duct ectasia, mastitis and breast carcinoma.
Always begin palpation on the side with the "normal" breast. Angle the bed at 45o and position the patient with their hand under their head on the side to be examined.
During palpation of the various parts of the breast, define any lumps in terms of location, size, shape (regular/irregular), consistency (fluctuant/compressible/hard) and mobility. Mobility is best assessed by asking the patient to internally rotate their outstretched arm, thus pushing the lump against your hand, allowing you to determine fixity to underlying tissues or skin. At all points also assess for temperature and tenderness.
Around the areola
Begin by palpating the outer aspect of the breast. View the breast as a clock face, palpating each ‘hour of the clock’ from the outside towards the nipple in a clockwise direction. Next, palpate the axillary process between your thumb and index finger. The axillary process is a projection of breast tissue from the upper outer quadrant towards the axilla.
Throughout the exam, it is crucial to maintain the patient’s dignity and minimise exposure where necessary. For example, when examining the left breast, cover the right breast with a blanket. Once breast palpation is concluded, the remainder of the examination can be completed with the patient wearing a hospital gown.
Use the ventral aspect of the flats of your middle three fingers in palpation as these are the most sensitive.
An alternative method of palpation of this region is to divide the breast into four quadrants: upper and lower, inner and outer. Ultimately, it does not matter which technique is employed so long as the entire breast is thoroughly examined.
Upon the nipple/areolar complex
In a similar manner to above, palpate deep to the nipple/areola region itself. Then attempt to express discharge if possible by asking the patient to gently hold their nipple whilst you massage the breast towards the nipple. In the context of the history, it is important to appreciate whether the discharge is spontaneous or expressible, its colour, consistency, amount, duration and whether or not it is blood-stained (microscopic blood can be assessed with urine-testing sticks).
To complete breast palpation
Elevate the breast with the back of your hand to uncover any dimpling or features hidden from sight during the general inspection.
Then, repeat the aforementioned steps for the contralateral breast.
This method of describing lumps is applicable to any body region:
A small amount of fluid may be expressed from multiple ducts upon massaging. This can be clear, yellow, white or green in colour. Persistent single duct discharge or blood-stained (macroscopic or microscopic) discharge should be investigated to exclude periductal mastitis arising from
duct ectasia (green discharge),
duct papilloma (yellow discharge) or
ductal carcinoma in situ (red, bloody discharge). In the presence of a mass, bloody discharge is suggestive of an invasive carcinoma.
Palpate the regional lymph nodes. Irregularly shaped, rubbery and enlarged lymph nodes can suggest tumour cell metastasis. Lymph node palpation can be uncomfortable for patients. Hence warn them beforehand and check for any discomfort.
The 5 axillary nodes to palpate are:
Anterior: Palpate against pectoralis major/minor.
Posterior: Palpate against latissimus dorsi.
Apical: Palpate against glenohumeral joint.
Medial: Palpate against humerus.
Central: Palpate against lateral chest wall.
Repeat palpation for the contralateral axilla.
Palpate the supraclavicular fossa and the neck from behind (akin to the respiratory/GI examination) systematically reviewing all cervical lymph chains.
Elevating one’s arm to reveal the axilla can be uncomfortable after a while, and so you may wish to support the patient’s arm. When, for instance, examining the right axilla, hold the patient’s right arm with your right hand and examine with your left hand.
Normally, lymph nodes are impalpable. A significant amount of lymphatic drainage of the breast is towards the axillary lymph nodes. As a result, the first sign of tumour cell metastasis will be irregularly shaped, enlarged and/or firm/rubbery lymph nodes.
Finally, assess three critical secondary sites for metastatic breast cancer:
Vertebral column: Run the side of hand down the spine determining any regions of bony tenderness.
Liver: Palpate and percuss for hepatomegaly.
Lung: Auscultate for lung involvement and malignant pleural effusions.
Concise breast history
Below are the key elements which should be determined in taking a breast history.
Breast cancer risk factors:
Family history of breast or ovarian cancer.
Significant irradiation of the chest wall.
Increased exposure to oestrogens over the patient's lifetime.
Other focus points:
Relationship of lump size and number of lumps to the patient's menstrual cycle.
Relationship of breast pain to the patient's menstrual cycle.
Rate of growth of lump.
Recent breast trauma.
Constitutional symptoms of malignancy (FLAWS).
Complete the examination by offering to obtain a breast-focussed history, conduct age-appropriate imaging (<35Y = Ultrasound, ≥35Y = Mammography) and request for a biopsy if indicated.
Breast imaging enables suspicious lumps to be further characterised in terms of density, margins and the detection of pathological, irregular microcalcifications. USS is preferred in patients less than 35 years of age, as young breast tissue is dense and difficult to evaluate by radiography.
Tissue biopsy comprises of either fine needle aspiration (FNA) or core biopsy, and informs management/prognosis. FNA is a minimally-invasive, cytological investigation, for identification of cell type and hormone receptor status. Core biopsy, is a histological investigation, which enables the malignant invasion of surrounding structure to be determined.
When assessing each other, please click on each list item as you go along. Doing so will turn the list item green. Make careful note of any steps missed at the end.
We recommend completing any examination or procedure in under 10 minutes, but you can adjust the timer to suit your needs.
Introduction: “Hello, I’m SimpleOSCE and I am a medical student. I need to perform and examination of your breasts today, would that be okay? Can I confirm your name and DOB? Thank you.”
"For the purpose of this examination the examiner will act as a chaperone."
Give the patient privacy to undress from the waist up.
Ask about pain and discomfort.
Ask the patient to stand or sit upright.
With the patient's arms by their side, inspect the breasts for: size, scars, asymmetry, contour, local swelling, erythema, puckering, nipple inversion.
Ask the patient to put their arms behind their head and continue the inspection.
Ask the patient to press firmly on their hips and continue the inspection.
Position the bed at a 45o angle and ask the patient to lie down.
Ask the patient if they have noticed any pain, lumps or discharge and on which breast.
Ask the patient to place their hand behind their head on the side of the "normal" breast and cover the suspected "abnormal" breast with a blanket.
Palpate the breast systematically.
Palpate the axillary tail.
Palpate the areola.
Ask the patient to squeeze for nipple discharge.
Palpate the axillary lymph nodes for lymphadenopathy.
Cover the breast.
Repeat steps 12-18 with the opposite breast.
Palpate the cervical lymph nodes for lymphadenopathy.
Auscultate the lung bases for lung metastasis.
Palpate and percuss the liver for hepatomegaly (liver metastasis).
Palpate the vertebral column for spinal metastasis.
Thank the patient and give privacy to dress.
Thank the patient and finish.
"To conclude, I would like to take a full history, ultrasound/mammography and take a biopsy if indicated.”