Differentials
| Presenting Feature | What might it be? | What might I find? | |
|
Breast lump |
Breast cancer |
Older patient aged >30, may have family history of cancer.
May be generally unwell e.g., weight loss, appetite loss. Visual change e.g., skin tethering or puckering, nipple inversion. Hard, irregular, fixed, painless lump. |
|
|
Fibroadenoma |
Younger patient aged 20-40.
Painless, smooth, mobile, well defined lump. |
||
|
Lipoma |
Longstanding lump with no skin changes.
Soft, painless mobile lump. |
||
|
Cyst |
Older patient aged 30-50, or perimenopausal patient.
Smooth, mobile, fluctuant; size varies with menstrual cycle. |
||
|
Fat Necrosis |
Patient with recent breast trauma, radiotherapy or surgery.
Painless, firm, irregular, fixed lump +/- skin dimpling. |
||
|
Breast abscess |
Any patient demographic, may be lactational.
May have systemic upset e.g., fever, tachycardia, myalgia. Swollen, fluctuant, tender lump +/- pus from nipple. |
||
|
Breast pain |
Cyclical mastalgia |
Younger patient who is menstruating.
Bilateral painful breasts in luteal phase of menstrual cycle. Other associated pre-menstrual symptoms e.g., headache. |
|
|
Non-cyclical mastalgia |
Older patient aged 40-50.
Localised pain, may originate from breast, chest wall, skin. |
||
|
Breast rash |
Mastitis |
Breast-feeding patient, may be systemic upset e.g.,. fever.
Erythema, tenderness and warmth in focal area of breast. |
|
|
Nipple candida (thrush) |
Breast-feeding patient, may have had recent antibiotics.
Sore, cracked, flaky, itchy nipple & areolar skin. Baby may have oral thrush or candida nappy rash. |
||
|
Breast cancer |
Older patient aged >30, may have family history of cancer.
Paget’s – hard, crusty, bleeding, red, oozing nipple/areola. Inflammatory breast cancer – skin redness, thickening. |
||
|
Nipple discharge |
Galactorrhoea |
Patient producing breast milk when not pregnant/feeding.
May be taking culprit medications e.g., antipsychotics. May have prolactinoma & have headache/visual change. May have endocrine disorder e.g., PCOS, hypothyroidism. |
|
|
Mammary Duct Ectasia |
Perimenopausal woman, history of smoking.
White/grey/green nipple discharge, +/- pain or inversion. |
||
|
Intraductal Papilloma |
Age between 35-55, may be incidental from mammogram.
Clear/bloody nipple discharge, +/- pain. |
||
Checklist
|
Preparation |
Wash – Name – Explain | |
| Chaparone | ||
| Allow to undress | ||
| Position patient sat on edge of couch | ||
| Expose patient | ||
| General Inspection | Body habitus | |
| Colour | ||
| Clues in bed space | ||
| Inspection of breasts from front and sides | ||
| Inspection of breasts with hands on hips | ||
| Inspection of breasts with hands behind head | ||
| Closer Inspection | Asymmetry | |
| Skin colour | ||
| Scars | ||
| Skin changes | ||
| Areola changes | ||
| Nipple changes | ||
| Palpation | Reposition to reclining 45° | |
| All quadrants | ||
| Sub-areolar tissue | ||
| Tail of Spence | ||
| Axilla | ||
| Finishing | Re-cover patient | |
| Wash hands |
Explanation
Preparation
Wash, name, explain:
- Wash your hands
- Introduce yourself by name and role
- Check the patient’s name and date of birth
- Explain the procedure and get consent
- Explain the presence and purpose of the chaperone
“I have been asked to carry out a breast examination. This will involve looking at and pressing on both breasts and underarm areas. You can ask me to stop at any time. There will be a chaperone present whilst I carry out this examination. Are you happy for me to do that?”
Ask the patient to remove clothing from the upper body, including their bra.
Allow the patient to cover with a sheet until you are ready to begin the examination.
General Inspection
Look at the patient and around the bed space for useful clinical signs:
- Body habitus – are they overweight or underweight?
- Signs of recent weight change (e.g., Loose skin)
- Colour (e.g., Pale, jaundiced)
- Clues in the bed space (e.g., medication packets, cigarettes)
Ask the patient to sit on the edge of the couch and inspect the breasts from the front and sides. Inspect the breasts in 3 positions: relaxed with arms by the sides, hands pressed onto hips tensing chest wall exaggerating any skin tethering and hands placed behind the head stretching the skin and again exaggerating any tethering.
Closer Inspection
Inspect both breasts for:
- Asymmetry (e.g., Differences in size or shape)
- Skin colour (e.g., erythema)
- Scars (e.g., previous breast surgery or cosmetic change)
- Skin changes (e.g., tethering, fixation or puckering)
- Peau d’orange – “orange peel”-like skin
- Nipple changes (e.g., inversion or eversion – ensure you establish what is normal for the patient)
- Nipple discharge – ask patient to express
- Changes to the nipple/areola skin (e.g., dry, scaly, inflamed)
Palpation
Position the patient sat back at 45 degrees. Examine both breasts, starting on the side without the abnormality noted by the patient. Ask the patient to place the hand of the side being examined behind their head.
Using the flat of your fingers, palpate the following areas: all four quadrants of the breast (upper outer, upper inner, lower outer & lower inner), subareolar tissue underneath the areola & nipple, tail of spence i.e. the tail of breast tissue towards the axilla and finally palpate the axilla itself.
Possible methods for palpation include: vertical, quadrants, spirals, clock-face. As long as you thoroughly examine the breast it does not matter which method is used; experiment and find which method works best for you.
Assessment of Breast Lumps
If you palpate a lump in the breast or axilla, you need to assess:
- Location – which quadrant/where on the clock face is the lump.
- Size, shape & consistency (e.g., soft, firm, hard, fluctuant, smooth, irregular
- Mobility – is the lump mobile or fixed to chest wall/underlying structures?
- Overlying skin changes, tenderness
Finishing
Thank the patient and allow them to cover themselves. Wash your hands.
[Illustrations – coming 2025]
Last updated Dec 2024
Head to members.zerotofinals.com for practice OSCE stations, including an interactive checklist, specific cases and clinical findings.
How to Learn Medicine Course