So now we're going to move on with the breast exam.
Now, it's important to recognize that
the breast exam, like the genital exam,
is a very sensitive part of
the exam 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.
It's also important to have a chaperone in the room
with you, particularly if you are a male clinician.
The last thing that I'll just mention is that
sometimes when you're palpating the breast,
if you have, if the patient has
fibroadenomas or other benign lumps,
they can be more tender or painful during menses.
So if it's possible to time the exam after menses,
that can be a bit more comfortable for the patient.
All right, with that, we'll move
on to inspection of the breasts.
So Shayla, if you're okay with it, if you
wouldn't mind just lowering your gown.
So on inspection, you're mostly
just looking for symmetry,
though, acknowledging that oftentimes one
breast may be slightly larger than another
and that's not unusual.
In order to get a full view of the contours of
the breast, I'll just ask you to lift up your arms.
That allows us to see each quadrant of the breast.
And we'll talk about the quadrants
a bit more detail in a moment.
We're also looking for any evidence of
nipple retraction or an dimpling of the skin,
which may be indicative of
an underlying breast cancer,
which oftentimes a breast cancer close to
the surface of the skin will pull the skin in.
And there's also the peau d'orange
type deformation that you can also see
with certain types of breast cancers.
I'm also looking for just any skin changes at all.
Patients with mastitis in the setting
of inflammation during breastfeeding,
and you could also see that at this point as well.
You can lower your arms now please, Shayla.
And with that, we will go ahead and
move on with palpation of the breasts.
So I'll take this opportunity just before I
move on to the remainder of the breast exam
to highlight the idea that we don't need
to wear gloves when you're performing
most of the physical exam, unless
you're dealing with an open wound
or obviously examining the genitalia,
there's no reason to put gloves on.
All they're going to do is reduce
the sensitivity of your finger pads,
the most sensitive part of your fingers,
and obscure things like in this case,
we're looking for little lumps
and bumps in the breasts.
So don't throw gloves on just because
you're examining another human being,
instead, just wash your hands.
All right, so with that, may I
move one side of the sheet aside?
I find it's useful to just examine
one breast at a time to maximize
the comfort and modesty of your patient.
And what I'll do is bring your arm a
little bit to the side, just like that
When we're examining the breast, typically, we
think of the breast as divided into four quadrants.
There's, of course, an upper inner
quadrant, upper outer, and then you've got a
lower outer and lower inner quadrant as well.
And then this is the tail of
Spence, which is glandular tissue
that is heading up towards the axilla.
The typical approach that we use for examining
the breast, there's two different types.
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 "lawnmower approach"
in so far as you just go up
and down with vertical lines,
one after the other, and you're perhaps more
likely to catch every single part of the breast
if you follow that methodical approach.
So I'm going to lay hands on, you know,
if it's okay and we're going to just start
on the medial aspect of the breast.
I'm going to displace your breast
a little bit up here as I do that.
And I do this kind of little superficial
circle and then deeper circle approach.
And I'm going to come back the other way.
It's not unusual, particularly
around the time of menses,
to find benign lumps, fiberoadenomas
which tend to be a bit more tender
and a bit more enlarged during menses .
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.
Is it mobile?
A lesion that is fixed to the skin or to the
anterior chest wall is more likely to be cancerous.
Tenderness, as I alluded to, a tender
lesion is less likely to be cancers as well,
whereas a firm fixed asymmetric lesion is
one that we're more concerned about cancer.
Again, superficial and then deeper.
Just making sure I'm catching all of the breast.
Sometimes the border between the end of glandular
tissue and the anterior chest wall can be subtle,
so it's important to go beyond that border
to make sure you don't miss anything.
And then I'm going to follow, like I said,
the tail of Spence up here
towards the axilla.
You're also going to want to perform
a lymph node, exam in the axilla.
And the lymph node exam for the
axilla is divided into four quadrants.
I like to think of it as a box with an
anterior, posterior, lateral, medial wall.
I'm going to start here by just going
underneath your armpit, if that's okay,
Looking for bumps there.
I'm going to do the anterior wall
where the pectoral muscles are,
the chest wall, which is the medial side, then the
posterior wall where your latissimus dorsi are.
Last you want to look at the nipple itself looking
for any asymmetry around the nipple or any dimpling.
Just to mention here that male patients who
have gynecomastia will actually have a similar
increase in glandular tissue around
the nipple as opposed to with obesity.
There tends to be just very
soft adiposity in that area,
whereas with gynecomastia, there really is a
firmness, as if you're palpating glandular tissue.
And now I'll just going to squeeze at the base of the
nipple to look for any expression of any discharge.
Patients who have breast cancer, that's
glandular in type may actually,
you'll express some blood or have
some other secretions when you do so.
And there's no evidence of anything
when I do that here on the breast.
So that completes the breast exam.