Breast Examination

Breast examination

Exposure: All of the top half of the trunk, Compare both breasts and Start with the normal side (MUST ASK FOR A CHAPERONE)

Inspection

Position (Patient sitting 90˚ then raise arms above her head then hands on her hip)

Breast Size, Symmetry, Contour, 6 areas (4 quadrants, Tail and Inframammary surface)
Skin Dimpling, Puckering, Peau d’orange, Cancer encrust, Discoloration, Nodule and Ulceration or SCAR
Nipple and areolae Destruction, Depression (retraction or inversion), Discoloration, Displacement, Deviation, Discharge and Duplication
Axillae and arms
Supraclavicular fossae

Palpation

Position (Patient sitting 45˚)
By Flat of fingers, Bimanual examination and Ask the patient to find the lump if you did not find it
Breast ‘6 areas’ (4 quadrants, Tail and Inframammary surface)

Lump

Number
Site
Shape
Size
Surface
Skin and color
Special signs

Relations to the surroundings

Mobility

Relation to skin
  • Freely mobile
  • Tethered
  • Fixed
Relation to muscles Hands by sides

Hands press in sides

Relation to chest wall
Other swellings
Temperature
Tenderness
Edge
Reducibility
Solid, fluid or gas Consistence

Fluctuation

Discharge
Milk each quadrant towards the nipple to know which duct is the source of the discharge
Axillae “axillary L.N.s” (anterior, medial, posterior, lateral and apical)
Supraclavicular fossae

General examination

Abdomen Hepatomegaly, Ascites and Nodule in Douglas pouch
Chest
Lumbar spine
  • Percussion
  • Movements
  • Straight leg raising and Ankle jerks

TAKING HISTORY FROM A PATIENT WITH breast PROBLEM

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

  • Pain
  • Lump

A painless lump

A painful lump

Pain and tenderness but no lump

  • Carcinoma
  • Cyst
  • Fibroadenoma
  • An area of fibroadenosis
  • An area of fibroadenosis
  • Cyst
  • Periductal mastitis
  • Abscess
  • Sometimes carcinoma
  • Cyclical breast pain
  • Non cyclical breast pain
  • Very rarely carcinoma
  • Discharge
Red Blood
  • Duct papilloma
  • Duct carcinoma
  • Duct ectasia
Pink Serum + Blood
Clear pale yellow Serum
Brown Breast secretions and debris
  • Duct ectasia
  • Cyst
Green
Black
Creamy white or yellow Pus
  • Duct ectasia
  • Lactation
Thin white Milk
  • Change of breast shape and size e.g.
    • Pregnancy
    • Carcinoma
    • Benign hypertrophy
    • Rare large tumors
  • Change in nipple and/or areola
    • Destruction
    • Depression (retraction or inversion)
    • Discolouration
    • Displacement
    • Deviation
    • Discharge
    • Duplication
  • Skin manifestations
    • Dimpling
    • Puckering
    • Peau d’orange
    • Cancer encrus
    • Discoloration
    • Nodule
    • Ulceration
  • Symptoms suggesting spread of malignancy.
Factors associated with increased risk of breast cancer
  • Race: White
  • Age: Older
  • Family history Breast cancer in mother, sister, or daughter (especially bilateral or premenopausal)
  • Genetics: BRCA1 or BRCA2 mutation
  • Previous medical history: Endometrial cancer
    Proliferative forms of fibrocystic disease
    Cancer in other breast
  • Menstrual history Early menarche (under age 12)
    Late menopause (after age 50)
  • Pregnancy Nulliparous or late first pregnancy

Differential diagnosis of different breast presentations

Discharge
 
Lactation (Physiological) Milk
Pregnancy (Physiological) Serous discharge
Duct ectasia
  • Serous
  • Creamy white, yellow or blood stained
  • It may be brown, green or black
Comes out from one or more ducts
Fibrocystic disease Clear, yellow, brown or green
Duct papilloma Blood or blood stained discharge From one duct
Duct carcinoma Rare cause of Blood or blood stained discharge From one duct
Contraceptive pills Serous or milky From multiple ducts
Hyperprolactinaemia Milky discharge From multiple ducts
Lump

Age

Pain

Surface

Consistency

Lymph nodes

Fibroadenoma 15-30 Painless Smooth and bosselated Rubbery

High mobility

Free axilla
Fibrocystic disease 35-50 Occasionally Indistinct mixed Free axilla
Solitary cyst 35-50 Occasionally Smooth soft to hard Free axilla
Carcinoma >35 Painless Irregular Usually stony hard Glands may be palpable
Change of breast shape and size
  • Pregnancy
  • Carcinoma
  • Benign hypertrophy
  • Rare large tumors
The causes of massive breast enlargement
  • Benign hypertrophy (usually bilateral)
  • Giant Fibroadenoma
  • Phylloides tumour
  • Sarcoma
  • Colloid carcinoma
  • Filarial elephantiasis
Change in nipple and/or areola
  • Duct ectasia
  • Carcinoma
  • Paget’s disease
  • Eczema
The cardinal signs of late cancer of the breast
  • Hard, non-tender, irregular lump
  • Tethering or fixation of the lump
  • Palpable axillary lymph nodes
Clinical Difference between Paget’s disease of nipple and eczema

Paget’s disease

Eczema

Site ‘laterality’

Unilateral

Commonly bilateral

Age

Usually at menopause

Commonly at lactation

Symptoms

No itching

Itching

Signs

Nipple is eroded

Intact nipple

Well defined

Ill defined

Breast lump may be felt

No lump

Treatment

No response to eczema treatment

Responds to treatment

Start

In the nipple

In the areola

Clinical Difference between inflammatory breast cancer and acute bacterial mastitis

Inflammatory breast cancer

Acute bacterial mastitis

Onset Gradual Acute
With no or low grade fever With high fever
Course Slower progress Rapid progress
Site and size More than one third of the breast One breast sector
Skin colour Dusky red Rosy or firy red
Pain Mildly tender Or non-tender lesion Markedly tender
Axillary lymph nodes Not Tender Tender
Treatment No response to antibiotics in one week is an indication for biopsy Cured by antibiotics Or form abscess
Diagnosis of a breast lump
Diagnosis of a breast lump