Dr Vivek Joshi, MD

 Assure patient privacy and warmth  Completely expose breasts  Observation/Inspection  In sitting position  Breast  Note color, size, symmetry  Look for thickening or increased pores  (Peau d’orange)  Look for supernumerary nipples  Nipples  Size, symmetry, shape  Inversion, direction they point  Rashes, ulcerations or discharges

 Observation/Inspection  Repeat in the supine position Special Positions  Place hands over head  Press palms together  Press hands against hips  If pendulous breasts lean forward

Inspection: Note if difference in size of two breasts Can create serious psychological problem Increase size of one breast: congenital anomaly, cyst formation, inflammation, tumor Superficial Appearance: Erythema: inflammation or inflammatory breast cancer Edema: denote inflammation or neoplasm Nipple: size, shape, general shape inversion, ulceration Nipple inversion can be caused by: congenital deformation, carcinoma, mammary duct ectasia with periductal fibrosis Ulceration: bilateral benign dermatological process, unilateral Rule out Paget’s disease of breast, a cancer

Palpation:  patient should be lying down so breast tissue flattened, thinned out  Use fingerpads of 2 nd, 3 rd, 4 th fingers  Use various pressure depending on what is palpated  Various techniques may be used but must be through, systematic, comprehensive  examine entire breast, periphery, tail, axilla; Circular  Wedge  Vertical strip

 Positioning of Patient and Palpation  keep same side shoulder flat against examining table  Lateral aspect: Have patient roll unto opposite hip, keeping shoulder against table. put her hand on her forehead  Here you will begin palpation in axilla, move down to bra line, then move in vertical strips up to clavicle medially to nipple  Position patient for medial exam  Medial aspect: hand put under the head with the elbow even with shoulder height  From nipple, move in vertical strips (bra line to clavicle) until you reach midsternum

 Examine breast tissue carefully for:  Consistency of tissue  Wide variation; some firmer glandular tissue and soft fat  Physiologic nodularity may be present before menses  Tenderness  Premenstrual, fibrocystic breast  Nodules, lumps or masses  Note location by quadrant /clock, centimeters from nipple  Size in centimeters  Shape: round, cystic, disc-like, irregular  Consistency: soft, firm, or hard  Delineation: well circumscribed or not  Tenderness  Mobility: in relation to skin, pectoral fascia, chest  Note elasticity / discharge

 Inspect nipple and areola for:  Nodules  Swelling  Ulceration  Discharge, color, quantity, presence of blood  Tenderness

 Have patient sitting, although lying down acceptable  Begin with Inspection  Look at skin for:  Rash  Infection  Unusual pigmentation

 Palpation  Have patient relax with arm hanging down, support wrist or hand (use same side: patient L arm, your L wrist)  Warn patient exam may be uncomfortable for short time  Cup your fingers together, reach as high as you can toward ape of axilla  Your fingers will lie directly behind pectoral muscles, pointing toward mid clavicle  Next, press your fingers toward chest wall slide them down trying to feel central nodes against chest wall  You may feel one or more soft, small (<1cm) non tender nodes

 If a suspicious node, or note axillary lesion, other lymph areas to examine include:  Pectoral nodes: grasp anterior axillary fold between your thumb and fingers with your fingers palpate inside border of pectoral muscle  Lateral nodes  From high in axilla, feel along upper humerus  Subscapular nodes  Step behind patient with your fingers feel inside muscle of posterior axillary fold  Infraclavicular  Supraclavicular

 The Male Breast  Inspect nipple and areola for:  Nodules  Swelling  ulceration  Palpate for  Nodules  Note if breast appears enlarged  Obesity vs glandular enlargement (gynecomastia)

 Nipple Discharge  Compress areola watching for discharge to appear through duct openings on nipple’s surface or nipple  Note color, consistency/quantity/location from where it came  The Mastectomy Patient  Inspect scar axilla carefully looking for unusual nodularity  Note color changes or inflammation  Note lymphedema, particularly in the axilla  Palpate using circular motion with two or three fingers  Pay special attention to upper outer quadrant / axilla  Patients with Breast Augmentation or reconstruction  Special attention to incision lines and breast tissue

 Breast and Axilla  Breasts symmetric without masses. Nipples without discharge. No axillary adenopathy Breast asymmetric, with R>L. Diffuse fibrocystic changes present. R breast, upper outer quadrant at 10:00, there is a single firm 2.3x2x1 cm oval shaped mobile, nontender mass with no overlying skin changes. No nipple discharge