Breast : Examination

                                                         Examination of Breast Lump

Position of patient [sitting, semi recumbent (45 degree), recumbent position, bending forward]

[A] Inspection

1.       Breast: compare both

·         Position ,size, shape

2.       Any swelling in the breast

·         Position in relation to breast quadrant

·         Extent, size and shape

·          Surface and margin

·         Skin over the swelling

3.       Any ulcer over the breast or over a swelling in the breast

·         Position and extent

·         Size and shape

·         Margin

·         Floor

4.       Skin

·         Color & texture, engorged veins

·         Dimpling, retraction, puckering

·         Peau d’orange, skin nodule

·         Ulceration, fungation

5.       Nipple:

·         Position (both nipples, vertical distance from clavicle, horizontal distance from midline)

·         Size, shape, discharge,

·         Surface of the nipple: Any cracks or fissure, any nipple retraction

7 Ds of Nipple (Norman Browse)

Ø  Destruction

Ø  Depression (retraction or inversion)

Ø  Discoloration

Ø  Displacement

Ø  Deviation

Ø  Discharge

Ø  Duplication

6.       Areola

·         Color, size, surface.

7.       Arm & thorax

·         Any edema of the arm

8.       Inspect in other positions

·         Arms raised over the head- for any nipple deviation or any skin changes

·         Patient sitting and leaning forward – to look for                whether both the breast fall forward equally or there is fixity of the diseased breast

·         Patient sitting and pressing her waist with the hands—to look for any evident skin changes

[B] Palpation

(Palpate with the flat of the fingers and not with the palm of the hand- Norman Browse)

1.       Local temp & tenderness

2.       Swelling

·         Position and extent in relation to the breast quadrant

·         Size( measure with Vernier caliper) and shape, surface and margin

·         Consistency

·         Fixity to skin, breast tissue, underlying  fascia & muscles, chest walls

·         Fixity to                Serratus anterior muscle for lumps in outer quadrant of breast

·         Cystic swelling –fluctuation and transillumination

3.       Ulcer over the breast    

·         Site, size and shape

·         Margin, floor, any discharge

·         Surrounding area, tenderness

·         Base of ulcer, mobility

4.       Examination of Lymph Nodes

·         Anterior, central, apical and the lateral -palpated from the front

·         Posterior or subscapular -palpated from the back

·         Right axilla is palpated with the left hand (except lateral and the posterior – same side hand)

Anterior group of axillary node

·         Right hand lifts the right hand of the patient and exposes the axillaàindex, middle and the ring finger of the left hand placed behind the anterior axillary fold and the thumb

·         Kept in frontà palpate along the lateral border of pectoralis major muscle

Central and apical group of lymph nodes

·         Lift right hand of the patient à place your left hand in the center of the axillaà right hand of the patient rests on your left forearmà your right hand       now steadies opposite shoulderàpalpate with the fingers against lateral chest        wall

Apical group of lymph nodes

·         Push the finger up in the apex of the axilla àkeep right hand over the ipsilateral supraclavicular fossa

Lateral group of axillary lymph nodes

·         Palpate on the right side with your right hand against the shaft of humerus between two axillary folds

Posterior or subscapular lymph node

·         Stands  on the   backàfor right side, support right hand by your left handà palpate along the posterior fold of the axilla by your right hand

SYSTEMIC EXAMINATION

·         Abdomen

Liver metastases

Ovarian metastases (Krukenberg’s tumor–ovarian metastases in premenopausal ovaries)

·         Chest

Signs of metastases—pleural effusion, consolidation

·         Bony tenderness

Any evidence of bony metastases (examination of spine, long bones and skull)