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The clinical breast examination is an

important component of womens health
care
it enhances detection of breast cancers
that mammography may miss
provides an opportunity to demonstrate
techniques for self-examination to the
patient.
 As you begin the examination of
the breasts
If she does
not, teach her
This may be a
Before you good technique
good time to
Be reassuring begin, let the and watch as
be aware that ask if she has
and adopt a patient know she repeats
women and noticed any
courteous and that you are the steps of
girls may feel lumps or other
gentle about to examination
apprehensive. problems and if
approach. examine her after you,
she performs a
breasts. giving helpful
monthly BSE.
correction as
needed.
 An adequate inspection requires full
exposure of the chest

but later in the examination you may

find it helpful to cover one breast while
you are palpating the other.
 Because breasts tend to swell and become
more nodular before menses
as a result of increasing estrogen stimulation

the best time for examination is 5 to 7

days after the onset of menstruation.
Inspect the breasts and nipples with the patient in the sitting position and disrobed to the waist.

A thorough examination of the breast includes careful inspection

Changes
Symmetry
Contours
Retraction

Views....

arms at sides
arms over head
arms pressed against hips
leaning forward

When examining an adolescent girl, assess her breast development according to Tanners sex
maturity ratings
 appearance of the skin
Redness from local infection
or Color
Thickening and prominent
inflammatory
pores suggestcarcinoma
a breast Thickening of the skin and
cancer. unusually prominent pores

size and symmetry of the

breasts.

Flattening of the normally

convex breast suggests
contour of the breasts
cancer. Look for changes such as masses,
dimpling, or flattening.
Compare one side with the other.
Asymmetry of directions in which
nipples point suggests an underlying
cancer.
characteristics of the nipples
Rash or ulceration in Pagets disease of size and shape
the breast
direction in which they point
any rashes or ulceration
ARMS AT SIDES any discharge
 To bring out dimpling or
retraction that may
otherwise be invisible
ask the patient to raise
her arms over her head,
then press her hands
ARMS OVER HEAD
against her hips to
contract the pectoral
muscles.
Inspect the breast
contours carefully in each
position.

HANDS PRESSED AGAINST HIPS

 If the breasts are large
or pendulous
it may be useful to have
the patient stand and lean
forward, supported by
the back of the chair or
the examiners hands.

LEANING FORWARD
 Inspect the skin of each axilla, noting
evidence of:
Rash
Infection
Unusual pigmentation
 Breast

Palpation is best performed when the breast

tissue is flattened.
patient should be supine.

Plan to palpate a rectangular area

extending from the clavicle to the inframammary fold or bra line
and from the midsternal line to the posterior axillary line and well into the axilla for the tail of
the breast.
 A thorough examination will take 3 minutes
for each breast.
Use the fingerpads of the 2nd, 3rd, and 4th
fingers
keeping the fingers slightly flexed.
Although a circular or wedge pattern can be
used
vertical strip pattern is currently the best
validated technique for detecting breast masses.
Palpate in small, concentric circles at each
examining point
if possible applying light, medium, and deep pressure.
You will need to press more firmly to reach the deeper tissues
of a large breast.

Your examination should cover the entire

breast, including the periphery, tail, and axilla.
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.
ask the patient to lie
with her shoulders
flat against the bed
or examining table
placing her hand at her
neck

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
Consistency of the tissues
There may be a firm
transverse ridge of
compressed tissue
Physiologic nodularity along the lower margin
Normal consistency may be present, of the breast,
varies widely increasing before especially in large
menses. breasts.
This is the normal
inframammary ridge, not a
tumor.
 Palpate carefully for any lump or
mass that is qualitatively different
from or larger than the rest of the
breast tissue.

This is sometimes called a dominant

mass and may reflect a pathologic
change that requires evaluation by
mammogram, aspiration, or biopsy.
Assess and describe the
characteristics of any nodule

Locationby quadrant or clock, with centimeters from

the nipple
Sizein centimeters
Shaperound or cystic, disclike, or irregular in contour
Consistencysoft, firm, or hard
Delimitationwell circumscribed or not
Tenderness
Mobilityin relation to the skin, pectoral fascia, and
chest wall.
 try to move the mass
itself while the patient
relaxes her arm and
then while she presses
her hand against her
hip.

attached to the
ribs and mobile mass becomes fixed
intercostal when the arm relaxes
muscles

attached to the if fixed when the hand is

pectoral fascia pressed against the hip
 The Nipple
Palpate each nipple, Thickening of the
noting its elasticity. nipple and loss of
elasticity suggest an
underlying cancer.
 To examine the left axilla, ask the patient to relax with the left arm
down.

Help by supporting the left wrist or hand with your left hand.

Cup together the fingers of your right hand and reach as high as you can
toward the apex of the axilla.

Your fingers should lie directly behind the pectoral muscles, pointing
toward the midclavicle.

Now press your fingers in toward the chest wall and slide them
downward, trying to feel the central nodes against the chest wall.

Of the axillary nodes, these are the most often palpable.

One or more soft, small (<1 cm), nontender nodes are frequently felt.
If the central nodes feel large, hard, or tender, or if there is a
suspicious lesion in the drainage areas for the axillary nodes, feel
for the other groups of axillary lymph nodes:

Pectoral nodes grasp the anterior axillary fold between

your thumb and fingers, and with your fingers palpate
inside the border of the pectoral muscle.

Lateral nodes from high in the axilla, feel along the

upper humerus.

Subscapular nodes step behind the patient and with

your fingers feel inside the muscle of the posterior
axillary fold.
Examination of the male breast may be brief but is
sometimes important.
Gynecomastia
imbalance of estrogens
Inspect the nipple and areola for nodules, swelling,
and androgens
or ulceration. sometimes drug-
related.

Palpate the areola and breast tissue for nodules. not gynecomastia and
suggests breast
cancer
If the breast appears enlarged
hard, irregular,
distinguish between the soft fatty enlargement of
obesity and the firm disc of glandular enlargement,
eccentric, or ulcerating
called gynecomastia nodule
Assessment of Spontaneous Nipple
Discharge.

If there is a history of spontaneous nipple

discharge, try to determine its origin

by compressing the areola with your index finger,

placed in radial positions around the nipple.
Watch for discharge appearing through one of the
duct openings on the nipples surface.

Note the color, consistency, and quantity

of any discharge and the exact location
where it appears
 unrelated to
a prior pregnancy and
lactation
leading causes are hormonal
and pharmacologic.

causative lesion is usually
benign, but may be malignant,
especially in elderly women.
benign intraductalpapilloma
in its usual subareolar location.
Note the drop of blood exuding from a
duct opening.
Examination of The Mastectomy Patient

Inspect the mastectomy scar and axilla carefully for

any masses or unusual nodularity.

Note any change in color or signs of inflammation.

Lymphedema may be present in the axilla and upper arm

from impaired lymph drainage after surgery.

Use a circular motion with two or three fingers.

Pay special attention to the upper outer quadrant and

axilla.
 It is especially
important to
carefully palpate the suggest recurrence
breast tissue and of breast cancer
incision lines of
women with breast
Masses, nodularity,
augmentation or change in color or
reconstruction inflammation
Esp. in the incision line
The office or hospital visit is an important time to teach the patient how to perform
the breast self-examination (BSE).

A high proportion of breast masses are detected by women examining their own
breasts.

Although BSE has not been shown to reduce breast cancer mortality, monthly BSE is
inexpensive and may promote stronger health awareness and more active self-care.

For early detection of breast cancer, the BSE is most useful when coupled with
regular breast examination by an experienced clinician and mammography.

The BSE is besttimed just after menses, when hormonal stimulation of breast tissue is
low.
1. Lie down with a pillow under your right shoulder.
Place your right arm behind your head.

2. Use the finger pads of the three middle fingers on

your left hand to feel for lumps in the right breast.

3. Press firmly enough to know how your breast feels.

A firm ridge in the lower curve of each breast is normal.
If youre not sure how hard to press, talk with your health
care provider, or try to copy the way the doctor or nurse does
it.
4. Press firmly on the breast in an up-and-down or strip pattern.
You can also use a circular or wedge pattern, but be sure to use the
same pattern every time.
Check the entire breast area, and remember how your breast feels from
month to month.

5. Repeat the examination on your left breast, using the finger pads of
the right hand.

6. If you find any changes, see your doctor right away.

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
dimpling of the skin
changes in the nipple
redness, or swelling.

3. If you find any changes

see your doctor right away.

 Mammography
specific type of imaging that uses a low-
dose x-ray system to examine breasts.
Mammogram
mammography exam ; used to aid in the
early detection and diagnosis of breast
diseases in women.
 Digital mammography
full-field digital mammography (FFDM)
mammography system in which the x-ray film is
replaced by solid-state detectors that convert
x-rays into electrical signals.
These detectors are similar to those found in
digital cameras.
The electrical signals are used to produce
images of the breast that can be seen on a
computer screen or printed on special film
similar to conventional mammograms.
 Computer-aided detection (CAD) system
use a digitized mammographic image that can
be obtained from either a conventional film
mammogram or a digitally acquired
mammogram.
The computer software then searches for
abnormal areas of density, mass, or
calcification that may indicate the presence of
cancer.
highlights these areas on the images, alerting the
radiologist to the need for further analysis.
mammography unit is a rectangular box
that houses the tube in which x-rays
are produced.

The unit is used exclusively for x-ray

exams of the breast, with special
accessories that allow only the breast
to be exposed to the x-rays.

Attached to the unit is a device that

holds and compresses the breast and
positions it so images can be obtained
at different angles
American Cancer Society recommends
monthly breast selfexamination beginning at age 20
clinical breast examination (CBE) by a health care professional every 3 years for women
between the ages of 20 and 39, and annually after age 40
yearly mammography for women 40 and older.

For women at increased risk, many clinicians advise a screening mammogram at

age 35 or 40, then every 2 to 3 years until age 50.

Mammography is less accurate when breast tissue is more glandular and dense,
especially before menopause
resulting in different recommendations about benefits of mammography for women in the 40-to-50
age group.

For women aged 50 to 69

mammography and CBE are widely recommended every 1 to 2 years.

After age 70

benefits of mammography are less well studied, and testing should be considered on an
individual basis.