OnExam

Setting Up

  • Male students/doctors should have a female chaperone in the room when possible.
  • Have the patient remove their top and bra and cover themselves with a sheet or gown. When examining, expose only the amount of skin necessary to ensure patient comfort.
  • Inspection

    Conduct primarily with the patient seated and arms hanging loosely at their side.
    Examine both breasts.

    Look for:

    • Skin
      • Colour
      • Thickening
      • Abnormal pores (peau d'orange sign)
      • Supernumerary nipple
    • Axillae for rash, inflammation, lymphadenopathy or unusual pigmentation
    • Breasts
      • Size
      • Symmetry
      • Contour
      • Masses
      • Dimpling* (this may require changing the patient's position)
    • Nipples
      • Size
      • Shape (inversion or eversion)
      • Pointing direction
      • Rashes vs. Ulcerations
        • Paget's disease vs. atopic dermatitis
      • Discharge (serous, bloody, or coloured)

    *Dimpling or retraction of breast may be elicited with different positions:

    • Raising arms overhead
      • Dimpling/retraction a sign of malignancy
    • Pressing hands at hips to contract pectoral muscles
      • Dimpling/retraction in benign lesions, posttraumatic fat necrosis, ectasia of mammary duct or malignancy
    • If breasts large and/or pendulous, having patient stand and lean forward may be beneficial
      • Retraction in malignancy

    In males

    • Inspect the nipple and areola for swelling, ulceration or nodules
    • Inspect the axilla for rashes, infection, abnormal pigmentations (may suggest internal malignancy)

    Palpation

    Breasts

    Position the patient supine. If patients are large, palpate with patient in oblique position (supine, arm raised on side of breast being examined, hips turned away from examiner).

    • Always palpate both breasts.
    • Palpate each breast for three (3) minutes
    • Breast boundaries: rectangular area bordered by clavicle, midsternal line, midaxillary line, and bra line
    • Use pads of index, middle and ring finger to palpate in concentric circles each with increasing levels of pressure (superficial, intermediate, and deep)
    • Use a vertical stripe pattern to ensure the entire breast is palpated.
    • Vertical stripe pattern
      • Begin in axilla, moving inferiorly down midaxillary line to bra line; shift medially then move superiorly towards clavicle; continue moving medially along strips between clavicle and bra line until midsternum is reached; each strip should be overlapping.
      • Be cognizant of capturing the tail of spence (axillary tail of the breast) during palpation.
    • Note the:
      • Consistency
      • Tenderness
      • Lumps
        • Location quadrant/clock position, distance from nipple
        • Size
        • Shape: round, irregular
        • Consistency: soft, hard
        • Delimitation: clear borders, lack of clear borders
        • Tenderness
        • Mobility (in relation to skin and chest wall)
    • Test for nipple discharge
      • Have the patient attempt to elicit discharge via areola compression; or use index finger to compress areola in radial positions around the nipple, noting:
        • Colour
        • Consistency
        • Volume
        • Odour
    • Remember to palpate scars from breast augmentation, reconstruction, or mastectomy
    • In male patients, differentiate between fatty enlargement vs. the glandular enlargement of gynecomastia

    Axillae

    • Sometimes best to do this after inspection, while the patient is still seated
    • Use left hand for right axilla and right hand for left axilla
    • Inform patient of the potential discomfort associated with the exam
    • Check for size, location, consistency and mobility of lymph nodes (normal if mobile and not tender or hard)

    • Central
      • Midway between anterior and posterior axillary folds, towards middle of clavicle
    • Lateral
      • Along medial aspect of upper humerus
    • Subscapular
      • Along lateral border of scapula, deep in posterior axillary fold
    • Pectoral
      • Along lower border of pectoralis major inside anterior axillary fold
    • Infraclavicular
    • Supraclavicular

    References

    1. Bickley LS. Bates' Guide to Physical Examination and History Taking. 11th Ed. Philadelphia: Lippincott, Williams & Wilkins; 2013.
    2. Jarvis C. Physical Examination & Health Assessment. Toronto (ON): Elsevier; 2009.
    3. Lincoln M, McSheffrey G, Tran C, Wong D. Essentials of Clinical Examination Handbook. 6th Ed. Toronto: University of Toronto Medical Society; 2010.