Assessment of the Breast – Advanced (Nursing)

by Stephen Holt, MD, MS

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    00:00 So, now we're going to move on with the breast exam.

    00:03 Now, it's important to recognize that the breast exam, like the genital exam is a very sensitive part of the exam.

    00:08 And it's important to walk through the entirety of the exam with your patient in advance to make sure they know what to expect.

    00:14 It's also important to have a chaperone in the room with you, particularly if you are a male clinician.

    00:19 The last thing that I'll just mention is that sometimes when you're palpating the breast, if the patient has fibroadenoma or other benign lumps, they can be more tender or painful during menses.

    00:30 So, if it's possible to time the exam after menses.

    00:34 That can be a bit more comfortable for the patient.

    00:37 All right. With that we'll move on to inspection of the breast.

    00:40 So, Sheila if you're okay with it.

    00:42 If you wouldn't mind just lowering your gown.

    00:44 So, on inspection, you just mostly just looking for symmetry.

    00:49 Though acknowledging that often times one breast may be slightly larger than another and that's not unusual.

    00:55 In order to get a full view of the contours of the breast.

    00:58 I'll just ask you to lift up your arms.

    01:00 Great. That allows us to see each quadrant of the breast.

    01:04 And we'll talk about the quadrants in a bit more detail in moment.

    01:07 We're also looking for any evidence of nipple retraction or any dimpling of the skin which may be indicative of an underlying breast cancer.

    01:15 Which often times a breast cancer close to the surface of the skin will pull the skin in.

    01:19 And there's also the Peau d'orange type deformation that you can also see with certain types of breast cancers.

    01:26 Mostly looking for just any skin changes at all.

    01:29 Patients with mastitis in the setting of inflammation during breast feeding.

    01:33 And you could also see that at this point as well. You can lower your arms now, please Sheila.

    01:37 And with that, we will go ahead and move on with palpation of the breasts.

    01:43 All right. So, with that. May I move one side of the sheet aside? I find it useful to just examine one breast at a time to maximize the comfort and modesty of your patient.

    01:54 And what I'll do is bring your arm a little bit to the side, just like that.

    01:58 When we're examining the breast, typically we think of the breast is divided into four quadrants.

    02:03 There is of course an upper inner quadrant, upper outer and then you've got a lower, outer and a lower inner quadrant as well.

    02:09 And then this is the Tail of Spence which is glandular tissue that is heading up towards the axilla.

    02:16 The typical approach that we use for examining the breast, there's two different types.

    02:20 There's kind of a going in a circle approach and then an approach that appears to be somewhat more evidence based is called the lawn mower approach.

    02:29 In so far you just go up and down with vertical lines, one after the other.

    02:34 And you'll perhaps more likely to catch every single part of the breast if you follow that methodical approach.

    02:40 So, I'm going to lay hands on you now if it's okay.

    02:42 We're going to just start on the medial aspect of the breast.

    02:45 I'm going to displace your breast a little up here as I do that.

    02:48 I do this kind of little superficial circle and then deeper circle approach.

    03:03 And then I'm going to come back the other way.

    03:07 It's not unusual particularly around the time of menses to find benign lumps.

    03:15 Fibroadenomas, which tend to be a bit more tender and a bit more enlarge during menses.

    03:22 And the characteristic features of lumps that you're looking for and you want to characterize are: is the lump round? Lesions that are fairly symmetrical and round are more likely to be benign.

    03:37 Is it mobile? A lesion that is fixed to the skin or to the interior to chest wall is more likely to be cancerous.

    03:45 Tenderness as I alluded to. A tender lesion is less likely to be cancerous as well.

    03:52 Whereas a firm, fixed, asymmetric lesion is one that we're more concerned about cancer.

    04:14 Again, superficial and then deeper. Just making sure I'm catching all of the breast.

    04:47 Sometimes the border between the end of glandular tissue and the interior chest wall can be subtle.

    04:54 So, it's important to go beyond that boarder to make sure you don't miss anything.

    05:02 And then I'm going to follow like I said the Tail of Spence up here towards the axilla.

    05:11 You're also going to want to perform a lymph node exam in the axilla.

    05:14 And the lymph node exam for the axilla is divided into four quadrants.

    05:17 I'd like to think of it as a box with an interior, posterior, lateral, medial wall.

    05:20 I'm going to start here by just going underneath your armpit if that's okay.

    05:24 Looking for bumps there.

    05:26 Then I'll do the interior wall where the pectoralis muscles are.

    05:29 The chest wall which is the medial side.

    05:32 And then the posterior wall where your latissimus dorsi are.

    05:35 Lastly, you want to look at the nipple itself.

    05:38 Looking for any asymmetry around the nipple or any dimpling.

    05:41 Just to mention here that male patients who have gynecomastia will actually have a similar increase in glandular tissue around the nipple.

    05:51 As opposed to with obesity, they tend to just be very soft, adiposity in that area.

    05:57 Whereas with gynecomastia there really is the firmness as if you're palpating glandular tissue.

    06:02 And now, I'll just going to squeeze at the base of the nipple to look for any expression of any discharge.

    06:07 Patients who have breast cancer, that's a granular in tight may actually, you'll express some blood or have some other secretion when you do so.

    06:17 And there's no evidence of anything when I do that here on the breast.

    06:21 So, that completes the breast exam.

    About the Lecture

    The lecture Assessment of the Breast – Advanced (Nursing) by Stephen Holt, MD, MS is from the course Assessment of the Breast (Nursing).

    Included Quiz Questions

    1. Asymmetric
    2. Symmetric
    3. Mobile
    4. Tender
    1. Glandular tissue lateral to the upper outer quadrant of the breast
    2. An orange tinge of the skin which is associated with breast cancer
    3. A line of blue-tinged skin originating from the nipple up into the upper inner quadrant associated with mastitis
    4. The area of the breast medial to the inner quadrants where the breast meets the sternum
    1. Retracted nipple
    2. Peau d’orange
    3. Mastitis
    4. One breast being slightly larger than the other
    5. Fibroadenoma

    Author of lecture Assessment of the Breast – Advanced (Nursing)

     Stephen Holt, MD, MS

    Stephen Holt, MD, MS

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