Examinations & Procedures - Part 2: Breast Examination

1. Gender Related Examinations

1.2. Breast Examination

You are SHO in the department of breast surgery where you are asked to see Mrs Dean who is 47 year old, previously fit and well, now presented with newly discovered lump in her breast. Your task is to take focused history, perform relevant examination and talk to her regarding further management.

BREAST EXAMINATION

As a doctor, performing a detailed breast examination involves a more comprehensive evaluation of the breasts, including a clinical breast examination (CBE) and potentially imaging tests, such as mammography or ultrasound. Here are the steps for a detailed breast examination:

Introduction: Introduce yourself to the patient, explain the procedure, and obtain their consent.
Medical History: Take a detailed medical history, including any personal or family history of breast cancer, prior breast biopsies, or other breast abnormalities.
Get chaperone: As this is an intimate examination, it is important that you get a chaperone to ensure privacy.
Inspection: Begin by visually inspecting the breasts for any asymmetry, skin changes, nipple retraction, or other abnormalities. Also, assess the patient's general body habitus and look for signs of lymphadenopathy.
Palpation: Palpate the breasts and axillary lymph nodes using a systematic approach. Divide the breast into four quadrants and palpate each quadrant with the pads of your fingers using a circular motion, feeling for any lumps, masses, or areas of thickening. Pay special attention to the tail of Spence, the area where the breast tissue extends into the axilla. Palpate the axillary lymph nodes for any enlargement or tenderness.
Nipple Discharge: Assess the nipple for any discharge and collect a sample for cytologic analysis if present.
Mammography or Ultrasound: Consider mammography or ultrasound as indicated based on the patient's age, medical history, and physical examination findings. If you detect any abnormalities, such as a palpable mass or suspicious nipple discharge, imaging tests may be necessary to evaluate further.
Documentation: Document your findings in the patient's medical record, including any abnormalities, location, size, shape, consistency, and mobility.
Follow-up: Recommend appropriate follow-up based on your findings. For example, if you detect a suspicious mass, you may recommend a biopsy or refer the patient to a breast specialist for further evaluation.

Performing a detailed breast examination requires good communication skills and sensitivity to the patient's concerns. Be sure to explain each step of the procedure to the patient, answer any questions they may have, and provide emotional support as needed.

Breast insepection in five positions

During a breast examination, visual inspection of the breasts is typically performed in five different positions to assess the shape, size, symmetry, and any visible abnormalities. The five positions for breast inspection are:

Sitting upright: The patient is seated with their arms at their sides. This position allows the examiner to observe the overall shape and symmetry of the breasts, as well as any skin changes, dimpling, or nipple retraction.
Leaning forward: The patient leans forward at the waist, which allows for gravity to pull the breasts downwards, revealing any changes in the skin or tissue of the breasts.
Hands on hips and leaning forward: The patient leans forward with their hands on their hips. This position allows the examiner to observe any asymmetry, contour changes, or nipple retraction.
Breast lifted up: To inspect underneath the breast, you can ask the patient to lift their breast with one hand while you visually inspect the skin and tissue underneath. You may also use your own hand to lift the breast and inspect underneath. You can use your fingers to palpate and feel for any lumps, masses, or areas of tenderness.
To ask the patient to squeeze their nipple, you can explain the procedure to them and provide them with clear instructions. Here's an example:
1. Ask the patient to use their thumb and index finger to gently squeeze the nipple.
2. Ask them to note any discharge or pain.
3. Ask them to repeat the procedure with the other nipple.
4. If any discharge is present, ask the patient to collect a sample of the discharge for cytologic analysis.
During this procedure, it's important to maintain a professional and sensitive approach. Ensure the patient feels comfortable and provide them with emotional support as needed. It's also essential to explain the purpose of each step of the examination to the patient and answer any questions they may have.
Lying at 45 degrees on back: The patient lies at 45 degrees on their back with their arms at their sides. This position allows the examiner to observe any asymmetry, skin changes, or nipple retraction.

Describing your findings

Describing a breast lump in a professional manner is an essential part of the breast examination. Here's an example of how to describe a breast lump:

Location: Describe the location of the lump using the clock-face method, which divides the breast into quadrants and describes the location of the lump as a distance from the nipple. For example, "the lump is located at 3 o'clock, 2 cm from the nipple."

Size: Describe the size of the lump in centimeters or inches. For example, "the lump measures 2 cm in diameter."
Shape: Describe the shape of the lump. Is it round, oval, irregular, or fixed?
Consistency: Describe the consistency of the lump. Is it hard, soft, firm, or rubbery?
Mobility: Describe the mobility of the lump. Is it fixed to the chest wall or does it move easily?
Tenderness: Describe any tenderness associated with the lump. Does it hurt when touched or pressed?
Skin Changes: Describe any skin changes overlying the lump. Is there any redness, swelling, or dimpling of the skin?
Nipple Discharge: Note if any discharge is present from the nipple and describe its color and consistency.

It's important to document your findings accurately and thoroughly in the patient's medical record. Use clear and concise language, avoid jargon or technical terms that the patient may not understand, and provide sufficient detail to help guide further evaluation or management of the patient's condition.

Actions required if you found a breast lump

If you discover a breast lump in your patient, it's important to take prompt action to evaluate the lump and determine its cause. Here are some steps you should follow:

Stay calm: Keep in mind that not all breast lumps are cancerous. It's important to reassure your patient that the lump may be benign.
Conduct a comprehensive breast exam: Perform a thorough breast examination to evaluate the lump and document its characteristics. Use the clock-face method to describe the location of the lump, note its size, shape, consistency, mobility, tenderness, skin changes, and nipple discharge.
Refer your patient to a specialist or breast clinic: Refer your patient to a specialist such as a breast surgeon, gynecologist, or radiologist for further evaluation and management. You can refer the patient to breast clinic where your patient will go through extensive assessment including detailed history, examination and further investigations. Your patient may need to undergo imaging tests such as a mammogram or ultrasound, and possibly a biopsy to determine the nature of the lump.
Provide emotional support: A breast lump can be a source of anxiety and stress for your patient. It's important to provide emotional support and reassurance throughout the diagnostic process. Encourage your patient to ask questions, express their concerns, and seek emotional support from family and friends.
Follow up with your patient: Once your patient has received a diagnosis and a treatment plan, it's important to follow up with them regularly to monitor their progress and ensure that they're receiving appropriate care.

Remember that early detection is key to successful treatment of breast cancer. If you have concerns about a breast lump or any other breast changes in your patient, don't hesitate to refer them for further evaluation and management.

Triple assessment of breast lumps

Triple assessment is a process used to evaluate breast lumps and determine their cause. It involves three components:

Clinical examination: The first step in triple assessment is a clinical examination of the breast by a healthcare professional. The healthcare professional will palpate the breast to feel for any lumps or abnormalities, and will also assess the surrounding tissue and lymph nodes for signs of cancer.
Imaging tests: The second component of triple assessment involves imaging tests such as mammography, ultrasound, or MRI. These tests are used to get a closer look at the breast tissue and to identify any abnormalities that may not be visible during a clinical examination.
Biopsy: The third component of triple assessment is a biopsy, which involves removing a sample of tissue from the breast for laboratory analysis. Biopsy may be done using a needle, which is guided by imaging, or through a surgical procedure. The tissue sample is examined under a microscope to determine whether it's cancerous or benign.

Triple assessment is a comprehensive approach to evaluating breast lumps and is considered the gold standard for diagnosing breast cancer. It allows healthcare professionals to make an accurate diagnosis, which is critical for determining appropriate treatment and ensuring the best possible outcome for patients.

Breast clinic and its role

Breast clinics in the UK are specialized healthcare facilities that provide a range of services related to breast health. Here are some of the roles of breast clinics in the UK:

Breast cancer screening: Breast clinics in the UK offer breast cancer screening services to detect breast cancer early, when it's most treatable. Screening usually involves a mammogram, which is an X-ray of the breast, and may also include a breast examination.
Diagnosis of breast conditions: Breast clinics in the UK provide diagnostic services to evaluate breast conditions such as breast lumps, nipple discharge, breast pain, and breast infections. Diagnosis may involve imaging tests such as mammography, ultrasound, or MRI, and may also include a biopsy to remove a sample of tissue for further testing.
Treatment of breast cancer: Breast clinics in the UK provide treatment services for breast cancer, which may include surgery, radiation therapy, chemotherapy, and hormonal therapy. Treatment is tailored to each patient's individual needs, and may involve a multidisciplinary team of healthcare professionals.
Support for patients with breast cancer: Breast clinics in the UK provide support services for patients with breast cancer, such as counseling, support groups, and rehabilitation services. These services are designed to help patients cope with the emotional and physical challenges of breast cancer and its treatment.
Research and education: Breast clinics in the UK may conduct research into breast cancer and other breast conditions, and may also provide education and training for healthcare professionals and the public on breast health and breast cancer prevention.

Overall, the role of breast clinics in the UK is to provide comprehensive, specialized care for patients with breast conditions, with a focus on early detection, accurate diagnosis, effective treatment, and supportive care.

Red flags

In cases where a patient presents with a breast lump, there are certain "red flags" or warning signs that healthcare professionals should be aware of. These include:

Rapidly growing or changing lump: A breast lump that is rapidly growing or changing in size or shape may be a sign of cancer.
Irregular or poorly defined lump: A breast lump with an irregular or poorly defined border may be a sign of cancer.
Hard, immobile lump: A breast lump that feels hard and is fixed in place may be a sign of cancer.
Skin changes: Skin changes over the lump, such as redness, puckering, dimpling, or retraction, may indicate cancer.
Nipple discharge: Bloody or clear nipple discharge from one breast only may be a sign of cancer.
Nipple changes: Changes in the nipple, such as inversion or flattening, may be a sign of cancer.
Breast pain: Breast pain alone is usually not a sign of cancer, but if it's associated with a lump or other breast changes, it may be a concern.
Family history: A personal or family history of breast cancer or other related cancers, such as ovarian or prostate cancer, may increase the risk of breast cancer.

If a patient presents with any of these red flags, it's important to refer them for further evaluation and management. Early detection and treatment of breast cancer can improve outcomes and increase the chances of successful treatment.

Examinations & Procedures - Part 2