PassMED: Medical Finals Examination Revision

Breast Examination

Nowadays for obvious reasons this is usually done on a dummy in the examination. In real life you should be chaperoned by a female nurse.

Introduce, explain, glance from end of bed. The patient should be chaperoned if possible.
Ask "where is the area of concern?"

The patient should be positioned sitting on the edge of the bed with her arms by her side, with the upper half of her body exposed.
Inspect her next with her hands on her head, and then hands on her hip whilst contracting the pectoralis muscles
Look for asymmetry, masses, dimpling (tethering to deep muscles, indicating cancer), scars, nipple inversion (cancerous), Paget's disease (eczematous changes of the nipple as a result of cancer).

Position the patient at 45 degrees, rolled slightly to the contralateral side being examined. Start examining the normal breast first. The hand of the side being examined should be behind her head.
Palpate the 4 quadrants and the central nipple (ask first, because it is sensitive). The most common site for malignancies is the upper, outer quadrant.
To palpate the axillae, relax her pectoral muscles by taking the weight of her arm in yours. Insert your fingers in to the axillae and move her arm closer to her side before feeling for lymph nodes.
Palpate the contralateral side.
Feel for infra and supraclavicular lymph nodes.

The age group is a strong clue to what the diagnosis will be:

15-30: Fibroadenoma: benign tumor with proliferation of glandular and stromal elements, due to estrogen
35-45: Fibroadenosis (no cysts) (also known as fibrocystic disease, chronic mastitis): Fibrosis, epitheliosis, adenosis ( "-is" implies overgrowth). Can be premalignant if has "atypical elements"
35-70: Cystic fibroadenosis
30+: Adenocarcinoma
Other: Duct papilloma (epithelial proliferation in ducts), traumatic fat necrosis, infections include cellulitis/mastitis, abscess (usually lactation/preg & staph aureus)

From www.cancer.gov