Breast examination is a common intimate examination that appears in OSCEs. It is also an essential skill in clinical practice, particularly in primary care and surgery.
General Principles
- Explain the process and reason for the examination
- Obtain informed consent
- Have a chaperone present, explain their role and document this (along with the full name of the chaperone)
- Allow the patient to get undressed and dressed in privacy
- Allow the patient to remain covered until just before the examination
- Ask about any areas of pain
- Ask the patient to point out any abnormalities they have noticed
- Use your examination to teach the patient how to self examine
Inspection
Ask the patient to sit on the side of the bed so you can inspect the breasts straight on, comparing both sides. Inspect the breasts in three positions:
- Relaxed with arms by the sides
- Hands pressed into the hip (tensing muscles of the chest wall to look for tethering)
- Hands placed behind the head
On inspection, look for:
- Asymmetry (size/shape)
- Scars
- Cosmetic augmentation (breast implants)
- Tethering, fixation or puckering of the overlying skin
- Nipple eversion/inversion
- Nipple discharge
- Skin colour (e.g., erythema)
- Peau d’orange (“orange peel”-like skin)
- Paget’s disease of the nipple
Peau d’orange is a description of an irregular patch of skin, which may be associated with inflammatory breast cancer. Blocked lymphatic drainage from the affected skin area causes superficial oedema (fluid collecting in the skin), making the skin thickened. The sweat ducts cause small dimples within the oedematous skin, leading to the thickened and dimpled appearance, similar to the surface of orange peel.
Paget’s disease of the nipple is an erythematous, scaly rash of the nipple region, resembling eczema. It can be itchy, inflamed or ulcerated. It may indicate underlying breast cancer and requires further investigation.
Palpation
Examine the patient sat back at 45 degrees. Ask them to put their hand, on the side being examined, behind their head.
Use the flat of your fingers to palpate, gently pressing the breast tissue down against the chest wall and rolling the tissue around to feel for any irregularities or lumps. Use the other hand to support the breast, if necessary.
Examine areas away from any abnormal or painful regions first. This helps you note the patient’s normal breast tissue and reduces the chances of missing other abnormalities.
There is no single best pattern for examining the breasts. Choose one where you feel confident you will properly cover all areas of the examination.
Possible methods to choose from are:
- Vertical up-and-down lines (moving up and down across the breast)
- Quadrants (assessing each quadrant in turn)
- Spirals (starting at the nipple and circling outwards in a spiral)
- Radial / wedge / clock face (moving outward or inward between the nipple and the outer areas of the breast, like the hands on a clock)
The important areas to cover are:
- The four quadrants of each breast (upper outer, upper inner, lower outer and lower inner)
- Subareolar area (under the nipple)
- Tail of Spence (the extension between the breast and the axilla)
- Axilla (armpit)
Assessing a Lump
If you find a lump, the key features to assess and describe are:
- Location
- Size
- Shape (round / oval / irregular)
- Consistency (soft / firm / hard / fluctuant)
- Margins (irregular / smooth)
- Mobile or fixed (tethered) to the skin or chest wall
- Tenderness (e.g., abscess)
- Skin colour (e.g., erythema indicating inflammation or infection)
- Nipple discharge (e.g., mammary duct ectasia or intraductal papilloma)
Additional Steps
Examine the neck for cervical and supraclavicular lymphadenopathy.
You can add additional examinations for areas of metastasis, such as the lungs, liver and bones.
Triple assessment of a breast lump requires:
- Clinical assessment (history and examination)
- Imaging (ultrasound or mammography)
- Histology (fine needle aspiration or core biopsy)
Last updated June 2021