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Breast Examination: Skills Training Manual Book Basic Surgical Skills Year Ii
Breast Examination: Skills Training Manual Book Basic Surgical Skills Year Ii
BLOCK 2.5
BREAST EXAMINATION
Skills Laboratory
Faculty of Medicine
Universitas Gadjah Mada
2010
BREAST EXAMINATION
BLOCK 2.5
Contributor:
dr. Kunta Setiadji, Sp.B (K) Onk
Oncology Subdivision, Department of Surgery
Faculty of Medicine Universitas Gadjah Mada/ Dr. Sardjito General Hospital
Yogyakarta
dr. Artanto Wahyono, Sp.B
Oncology Subdivision, Department of Surgery
Faculty of Medicine Universitas Gadjah Mada/ Dr. Sardjito General Hospital
Yogyakarta
Co-Contributor:
dr. Yulia Wardhani
PREFACE
Medical faculty students should study and practice several clinical skills as
preparation for entering clinical rotation prior to becoming a certified doctor. Currently,
the medical profession compels medical students to be competent in clinical skills before
they directly deal with real patients experiencing real life medical cases. For this reason,
clinical skills are trained as early as possible. This clinical skills laboratory provides
opportunity for students to study and practice the clinical skills on their own.
The topic of this manual is one of the clinical skills topics that constitute the main
topic of Basic Surgical Skills, which will be studied continually in blocks throughout
undergraduate studies. Topics covered in the Basic Surgical Skills, which will be studied
in Year II, are as follows:
No.
Topics for Clinical Skills Training
1. Simple Skin Suturing
Block
2.1
( Conception, Foetal
Growth and Congenital
Anomaly)
2.
Circumcision
2.3
(Childhood)
3.
Breast Examination
2.5
(Adulthood)
It is important for students to recognize that all topics, including those listed
above, are interrelated. Therefore, students are expected to categorize the topics based on
the main topics, so that continuity from one topic to another can be achieved. We hope
that in the future, this manual for clinical skills training can be useful for students to
improve their skills, especially in physical examination; and for instructors who are
involved in providing the trainings.
Yogyakarta, February 2010
Contributor
TABLE OF CONTENTS
Preface
Table of Contents
Introduction
Objectives
Basic Concept
Anatomy of the breast
Common Breast Masses
Risk Factors for Breast Cancer
Visible Signs of Breast Cancer
Technique of Examination
The Female Breast
Anamnesis (Review of Specific Symptom)
Physical Examination
Inspection
Axillary Examination
Palpation
Examination of the nipple
The Male Breast
Breast Self-Examination
Lesson Plan for Breast Enamination
Objectives
Activities
Tools
Level of Competences
References
Checklist Breast Examination
Checklist Breast Examination
Checklist Teaching Breast Self Examination
Appendix 1 -- Sex Maturity Ratings In Girls : Breasts
Appendix 2 -- Safety Precaution
LESSON PLAN OF
BREAST EXAMINATION
A. General Objectives of Skills Training Year II
1. Students are able to explore data (communication, physical, procedural,
supporting examinations) and draw a conclusion from patients problems, the
sequence of diagnosis possibilities as well as to deliver the results to the patient.
2. Students are able to perform specific procedural actions relevant to patients
problems, by considering ethical aspects.
B. General Objectives of Breast Examination
1. Perform anamnesis on breast complaint.
2. Perform the breast examination by physician
3. Demonstrate techniques for breast self-examination to the patient
4. Determine the supporting examination to establish the diagnosis.
C. Level of Competence
Level of Competence for Clinical Skills :
The following is the division of competence level according to Miller Pyramid:
Level of Competence 1: Understanding and Explaining
The graduates of medical school possess theoretical knowledge concerning these
skills, so that they are able to explain concepts, theories, principles or indications,
performing procedures, emerging complications and others to their colleagues.
Level of Competence 2: Having seen or Having been demonstrated
The graduates of medical school possess theoretical knowledge concerning this
skill (concepts, theories, principles or indications, performing procedures,
complications and others). Besides, during their study, they had seen this skill or
this skill had been demonstrated to them.
Level of Competence 3: Having done or Having applied under supervision
The graduates of medical school possess theoretical knowledge concerning this
skill (concepts, theories, principles or indications, performing procedures,
complications and others). Besides, during their study, they had seen this skill or
this skill had been demonstrated to them or they had applied several times under
supervision.
Level of Competence 4: Able to perform independently
The graduates of medical school possess theoretical knowledge concerning this
skill (concepts, theories, principles or indications, performing procedures,
complications and others). Besides, during their study, they had seen this skill or
this skill had been demonstrated to them and they had applied several times under
supervision; in addition, they possess experience to use and apply this skill in the
context of doctor practices independently.
Physical Examination
Inspection of breasts
Palpation of breasts
1
1
2
2
3
3
4
4
D. Activities
First Session
No. Duration
1.
5 mins
Topics
Introductions
2.
15 mins
Review of History
Taking
3.
15 mins
4.
15 mins
Breast
examination
demonstration
Breast
examination
review and check
5.
30 mins
Practices
6.
10 mins
Break
Question and
answer
7.
30 mins
Practices
Second session
No. Duration
1.
15 mins
Topics
Introduction
Review
2.
15 mins
Overview and
demonstration
of BSE
3.
20 mins
Tools
Trainer introduce himself/herself
and gives general precautions of
the tools used in his session
Trainer discuss with the students
what is important in history taking,
ask the students to recall and
structure the question
Trainer demonstrate the
examination on a student, step by
step breast examination
One of the student demonstrate the
examination on other student
The other student give comments
and corrections. The demonstrator
may ask for doubt and difficulties
Students grouped to practice the
examination
Students sharing their doubts
,difficulties and comments after
first practices.
If there is no question
Trainer remind the important
things
Students grouped to practice the
examination
Vest
Vest
Vest
Vest
Tools
Trainer ask the students the
important things of History
Taking and breast examination
Trainer explains the importance
of BSE in the early diagnosis of
breast abnormalities, when to
do, how to do it
Using flip chart
One of the student demonstrate
the examination on other
Vest
Flip
chart
Vest
Flip
4.
30 mins
Practices
5.
10 mins
Break
Question and
answer
6.
30 mins
Practices
E. Tools
1. Manual Book
2. Breast Vest
3. Breast Self Examination Simulation
4. Breast Care Flip Chart
5. Breast Self Exam Form
6. Alkohol 70%
7. Gloves
student
The other student give
comments and corrections. The
demonstrator may ask for doubt
and difficulties
Students grouped to practice the
examination
Students sharing their doubts
,difficulties and comments after
first practices.
If there is no question
Trainer remind the important
things
Students grouped to practice the
examination
chart
Illustration Case
A 28-year-old woman came to you, complaining of a lump at her breast, which she
suffered-from, since 2 years ago. The lump did not getting bigger and was painless.
How to conduct breast examination to this patient?
Give guidance how to perform self breast examination!
Introduction
Breast cancer is the most common cancer in women worldwide, accounting for
more than 10% of all female malignancies. In the United States, the National Cancer
Institute estimates that 1 woman of every 8 (approximately 12.6%) will develop breast
cancer during her lifetime. Among the malignancies in women, breast cancer is the most
common cancer to develop and is the second most common cancer cause of death. It
accounts for 26% of new cancers in American women and 18% of cancer deaths. In 2000,
there were 184,200 new cases with 41,200 deaths in the United States. Mortality rates
have declined for white women younger than 55, probably as a result of more widespread
use of mammography and aggressive treatment regimens, but have increased for African
American women.
Once breast cancer has occurred in a family, the risk for other women in the same
family will develop breast cancer is significantly higher. First degree relatives, such as
sisters or daughters, have more than twice the risk of developing breast cancer if the
original patients developed cancer in one breast after menopause.Women with a family
history of premenopausal breast cancer in one breast have three times the risk If the
original patient had postmenopausal cancer in both breasts, the first degree relatives have
more than four times the risk. First-degree relatives of patients with cancer in both breasts
before menopause have nearly nine times the risk.
For screening of asymptomatic women target risk factors, including family
history. Risk factors for breast cancer are present in up to 55% of cases, and a positive
family history is present in additional 10%. The clinician and individual patient should
review age and demographic data, family history, reproductive history, and any prior
history of proliferative breast disease, especially if a biopsy has shown atypical
hyperplasia or lobular carcinoma in situ.
Rarely, men report about a breast mass. Breast cancer in men accounts for 1% of
all breast cancers and is usually diagnosed between the ages of 60 and 70. Risk factors
include estrogen exposure, including excess estrogen stimulation in Klinefelters
syndrome or cirrhosis, radiation exposure, and positive family history in female relatives.
Most common breast cancers are detected as painless masses noticed by either
the patient or the examiner during a routine physical examination. The earlier the
diagnosis, the better the prognosis. Screenings for breast cancer are best done by a
thorough clinical breast examination, breast self examination, and mammography.
Mammography is the most sensitive method for the detection of breast cancer and has
been demonstrated to reduce the breast cancer mortality rate recently.
BASIC CONCEPT
Anatomy of the breast
The female breast lies against the anterior thoracic wall, extending from the
clavicle and 2nd or 3rd rib down to the 6 th or 7th rib, and from the sternum across to the
midaxillary line. Its surface area is generally rectangular rather than round. The breast
overlies the pectoralis major and at its inferior margin, the serratus anterior.
To describe clinical findings, the breast is often divided into four quadrants based
on horizontal and vertical lines crossing at the nipple. An axillary tail of breast tissue
extends toward the anterior axillary fold (see figure 2).
The normal breast consist s of glandular tissue, ducts, supporting muscular tissue,
fat, blod vessels, nerves, and lymphatics. The glandular tissue consists of 15-25 lobes,
each of which drains into a separate excretory duct that terminates in the nipples. Each
ducts dilates as it enters the base of the nipple to form a milk sinus. This serves as a
reservoir for milk during lactation. Each lobe is subdivided into 50-75 lobules, which
drain into s duct that empties into the excretory duct of the lobe. Fibrous connective
tissue provides structural support in the form of fibrous bands or suspensory ligaments
connected to both the skin and the underlying fascia. Adipose tissue, or fat, surrounds the
breast, predominantly in the superficial and peripheral areas. The proportions of these
components vary with age, the general state of nutrition, pregnancy, exogenous hormone
use, and other factors.
Fig. 2
Fig. 3
Source: Bickley L.S. dan Szilagyi P.G. Bates Guide to Physical Examination and
History Taking. 9th edition. Lippicott Williams & Wilkins. 2007
The blood supply to the breast is carried by the internal mammary artery. The
breast has an extensive network of venous and lymphatic drainage. Most of the lymphatic
drainage empties into the nodes in the axilla. Other nodes lie beneath the lateral margin of
the pectoralis major muscle, along the medial side of the axilla, and in the subclaviar
region. The main lymph node chains and lymphatic drainage of the breast are shown in
figure 4.
Cysts
Cancer
15-25, usually
puberty and young
adulthood, but up
to age 55
Usually single,
may be multiple
30-50, regress
after menopause
except with
estrogen therapy
Single or multiple
round
Delimitation
Round, disclike,
or lobular
May be soft,
usually firm
Well delineated
Mobility
Very mobile
Mobile
Tenderness
Usually nontender
Often tender
Usual Age
Number
Shape
Consistency
Soft to firm,
usually elastic
Well delineated
Firm or hard
Not clearly delineated
from surrounding
tissue
May be fixed to
skinor underlying
tissue
Usually nontender
Fig. 5
Fig. 6
Source: Bickley L.S. dan Szilagyi P.G. Bates Guide to Physical Examination and
History Taking. 9th edition. Lippicott Williams & Wilkins. 2007
Skin Dimpling
Look for this sign with the patients arm at rest, during special positioning, and on
moving or compressing the breast, as illustrated in figure 7.
Nipple Retraction and Deviation
A retracted nipple is flattened or pulled inward. It may also be broadened, and feel
thickened. When involvement is radially asymmetric, the nipple may deviate or point in a
different direction from its normal counterpart, typically toward the underlying cancer.
(see figure 8.)
Fig. 7
Fig. 8
Source: Bickley L.S. dan Szilagyi P.G. Bates Guide to Physical Examination and
History Taking. 9th edition. Lippicott Williams & Wilkins. 2007
Fig. 9
Fig. 10
Source: Bickley L.S. dan Szilagyi P.G. Bates Guide to Physical Examination and
History Taking. 9th edition. Lippicott Williams & Wilkins. 2007
Investigations
Although an accurate history and clinical examination are still the most important
methods of detecting breast disease, there are a number of investigations that can asist in
the diagnosis:
Mammography. Soft-tissue radiographs are taken by placing the breast in direct
contact with ultrasensitive film and exposing it to low-voltage, high-ampere x-
rays. The dose of radiation is approximately 0.1 Gy, and therefore mammography
is very safe investigation which can be repeated.
Ultrasonography is particularly useful in young women with dense breast in
whom mammograms are difficult to interpret, and in distinguishingcyst from solid
lesions. It can also be used to localize impalpable breast lumps.
Needle biopsy/cytology. Histology can be obtained using a fine needle such as a
Tru-cut or Core-cut biopsy device under local anesthesia. Cytology is obtained
using a 21 0r 23 gauge needle and 10 ml syinge with multiple passes throughout
the lump without releasing the negative pressure in the syringe. The aspirate is
then smeared onto a slide which is air dried. Fine needle aspiration cytology
(FNAC) or Fine needle aspiration Biopsy (FNAB) is the least invasive tecnique
for obtaining a cell dagnosis, and is very accurate if both operator and cytologist
are experienced. However, false negativess d occur mainly through sampling
error, and invasive cancer cannot distinguished from carcinoma in situ.
Ductography demonstrates duct anatomy and pathology by injection of radioopaque contrast medium into a major lacteal duct and taking a radiograph. It is a
painful technique, rarely of value except in certain obsure cases of discharge
TECHNIQUE OF EXAMINATION
THE FEMALE BREAST
ANAMNESIS ( Review of Specific Symptoms)
The most important symptoms of breast disease are the following:
Symptom
MASS or
SWELLING
PAIN
NIPPLE
DISCHARGE
GENERAL
The interviewer should pay special attention to the family
SUGGESTION history of any woman presenting with symptoms of breast
disease. As indicated earlier, brest cancer may be a familial
disorder. The occurrence of breast disease in a close relative
and the age at which it developed are relevant to the patients
disease.
Ask the patient:
Have you had a mammogram? If so, When and what was
the result?
Have you had breast cancer?
Have you had any breast biopsies or breast surgery?
Have you ever had radiation treatments to your breasts?
Did your natural mother have breast cancer? If yes, Pre- or
post-menopausal? At what age was her diagnosis made?
Do you have a sister or daughter with breast cancer? If yes,
Pre- or post-menopausal? At what age was her diagnosis
made?
Do you use birth control pills?
[ AXILLARY EXAMINATION ]
The axillary examination is performed with the patient seated facing the examiner.
Examination of the axilla is best accomplished by relaxing the pectoral muscles. To
examine the right axilla, the patients right forearm is supported by the examiners right
hand. The tips of the fingers of the examiners left hand start low in the exilla, and, as the
patients right arm is drawn medially, the examiner advances the left hand higher into the
axilla. This technique is shown in figure 15 and 16. Palpate the supraclavicular,
subclavian, and axillary region.
The technique of using small, circular motion of the fingers riding over the ribs is
used for detecting adenopathy. Freely mobile nodes 3-5 mm in diameter are common and
are usually indicative of lymphadenitis secondary to minor trauma of the hand and arm.
After one axilla is examined, the other is evaluated by the examiners opposite hand.
[ PALPATION ]
The women is asked to lie down and is told that palpation of the breast is next.
The examiner stands at the right side of the patients bed. Although the examiner can
usually palpate each breast from the patients right side, it is often better with largebreasted women to examine the left breast from the left side.
The breast is best palpated by allowing it to lie evenly distributed over the chest
wall. Small-breasted women may lie with their arms at their sides, larger-breasted women
should be instructed to place their hands behind their head. A pillow placed beneath the
shoulder on the side being examined facilitates the examination.
In palpation of the breast, the examiner should use both the flat of the hand and
the fingertips. Palpation should be performed by the spokes of a wheel, concentric
circle, or the vertical strip method.
A. Spokes of a Wheel (Wedge) Methode
The spokes of a wheelmethod starts at the nipple (Fig 17 & 18). The examiner
should start the palpation by moving outward from the nipple to the 12 oclock
position. The examiner then should return to the nipple and move along the 1 oclock
position and continue the palpation around the breast
skin. The pads, not the tips, of the fingers, must be used for palpation. Using
dimensized circles, the examiner evaluates the breast at each of three different levels
of pressure light, medium, and deep. Each strip consists of nine or ten areas of
palpation, slightly overlapping the previous area, and each vertical strip is evaluated
with the three pressures. Although this method has been shown to be superior to the
other traditional types of breast palpation, it is more time-consuming and may be best
used by women for breast self-examination. These technique are illustrated in
figure17 and 18.
To examine the lateral portion of the breast, ask the patient to roll onto the
opposite hip, placing her hand on her forehead but keeping the shoulders pressed
against the bed or examining table. This flattens the lateral breast tissue. Begin
palpation in the axilla, moving in a straight line down to the bra line, then move
the fingers medially and palpate in a vertical strip up the chest to the clavicle.
Continue in vertical overlapping strips until you reach the nipple, then reposition
the patient to flatten the medial portion of the breast.
To examine the medial portion of the breast, ask the patient to lie with her
shoulders flat against the bed or examining table, placing her hand at her neck and
lifting up her elbow until it is even with her shoulder. Palpate in a straight line
down from the nipple to the bra line, then back to the clavicle, continuing in
vertical overlapping strips to the midsternum.
Fig. 25
examine your breast each month. Many healthcare professionals recommend using the
vertical (grid) pattern while lying down.
Use the flat surface of the three fingers to make overlapping, dime-size, circular
motions on the breast tissue. Apply light, medium, and firm pressure to examine all levels
of breast tissue.
Standing Position
1. Repeat the examination of both breasts while standing, with one arm behind your
head. The upright position makes it easier to check the upper outer part of the
breasts (toward your armpit). This is where about half of breast cancers are found.
You may want to do the upright part of the BSE while you are in the shower. Your
soapy hands will make it easy to check how your breasts feel as they glide over
the wet skin.
2. For added safety, you might want to check your breasts by standing in front of a
mirror right after your BSE each month. See if there are any changes in the way
your breasts look, such as dimpling of the skin, changes in the nipple, redness, or
swelling.
3. If you find any changes, see your doctor right away.
(see figure 32 and 33)
No
Step
1. Introduction
2.
Sitting Position
3.
Preparation
4.
Arms at Sides
5.
6.
Axillary examinations
Positioning
7.
Axillary examinations
palpation
Aspects
Self introducing and greetings
The examiner explain to the patient about
the procedure
The examiner ask and help patient to the
sitting position, seated on the edge of the
examination table, facing the examiner.
The examiner wash the hands using
alcohol 70%, then put the gloves on.
The examiner should ask the women to
remove her gown to her waist
The examiner ask patients to put her arm
at sides. Examiner should inspect:
- The appearance of the skin (colour
changes, thickening)
- The size and symmetry of the breasts
- The contour of the breasts (masses,
dimpling, flattening)
- The characteristics of the nipples (size,
shape, direction)
The examiner ask the patient to raise her
arms over her head,
then press her hands against her hips,
and leaning forward (if necessary),
The students should inspect breast contour
(dimpling, retraction)
The examiner seated facing the examiner,
to examine the right axilla, the patients
right forearm is supported by the
examiners right hand
The tips of the fingers of the examiners
left hand start low in the right axilla, and,
as the patients right arm is drawn
medially, the examiner advances the left
Feedback
8.
9.
Breast palpations
16. Conclusion
Demonstrate confidence
during performing skills
in front of patient
2.
Building and
maintaining adequate
relationship with
patients during the
whole consultation
2.
Exploration on patient
problem and summarize
the problem
2
Below
expectation
1
Unexpected
2
Below
expectation
3
Meet
expectation
4
Exceeding
expectation
5
Excellent
4
Exceeding
expectation
5
Excellent
Scale
1
Unexpected
Scale
3
Meet
expectation
Explanation:
Scale 1: Unable to demonstrate respect and norms + More than 80 % error
Scale 2: Below observers expectation (demonstrate minimal respect and norms + 60%-80% error)
Scale 3: Meet observers expectation (demonstrate minimal respect and norms + 40%-60% error)
Scale 4: Exceed observers expectation (demonstrate minimal respect and norms + 20%-40% error)
Scale 5: Excellent (demonstrate minimal respect and norms + less than 20% error)
Yogyakarta, ..
Instructor
()
No
Step
1.
Introduction
2.
Aspects
3.
Timing
4.
Fingers positions,
movements and pressure
5.
Paterns
6.
7.
Standing position
8.
Consult to physician
Aspects
Introducing Breast Self Examination
to a patient
Explaining Positive and negative
aspects of Brest Self Examination
Explaining time of Breast Self
Examination and the reason
Explaining to use the flat surface three
fingers to make overlapping, dimesize, circular motions on the breast
tissue. Apply light, medium, and firm
pressure to examine all levels of breast
tissue.
Explaining the paterns, recommended
vertical grid paterns,
Lie down with a pillow under your
right shoulder. Place your right arm
behind your head
Use the finger pads of the three middle
fingers on your left hand to feel for
lumps in the right breast. And vice
versa
Arm position behind your head,
Using soapy hand,
In front of mirror,
Look for any changes:
dimpling of the skin, changes in the
nipple, redness, or swelling.
If you find any changes
Feedback
Scale
1
Unexpected
2
Below
expectation
3
Meet
expectation
4
Exceeding
expectation
5
Excellent
3.
Demonstrate confidence
during performing skills
in front of patient
4.
Building and
maintaining adequate
relationship with
patients during the
whole consultation
4.
Exploration on patient
problem and summarize
the problem
Scale
1
Unexpected
2
Below
expectation
3
Meet
expectation
4
Exceeding
expectation
Explanation:
Scale 1: Unable to demonstrate respect and norms + More than 80 % error
Scale 2: Below observers expectation (demonstrate minimal respect and norms + 60%-80% error)
Scale 3: Meet observers expectation (demonstrate minimal respect and norms + 40%-60% error)
Scale 4: Exceed observers expectation (demonstrate minimal respect and norms + 20%-40% error)
Scale 5: Excellent (demonstrate minimal respect and norms + less than 20% error)
Yogyakarta, ..
Instructor
()
5
Excellent
REFERENCES
1. Bickley L.S. dan Szilagyi P.G. Bates Guide to Physical Examination and History
Taking. 9th edition. Lippicott Williams & Wilkins. 2007
2. Swartz, M.H. Textbook of Physical Examination : History and Examination. 4th
edition. W.B. Saunders Company. 2002
3. Atkins, K. Breast Care. (taken from http://www.HealthEdco.com )
4. Mann CV, Russell RCG, Williams NS (eds) edition Chapter 39. The Breast, In Baley
& Loves: Short Practice of Surgery, wenty-second, ELBS with Chapman & Hall,
London. 1995
Appendix 1
SEX MATURITY RATINGS IN GIRLS : BREASTS
Source: Bickley L.S. dan Szilagyi P.G. Bates Guide to Physical Examination and
History Taking. 9th edition. Lippicott Williams & Wilkins. 2007
Appendix 2
Safety Precaution of Breast Examination Tools
1. Before using the breast examination tool, make sure that you have cut your
finger nail.
2. Wash your hand, and use the gloves during the examination.
3. Do not mark using ink pen.
4. Use it carefully.
5. Follow the whole procedure and correct instruction.