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Breast Examination for Medical Student OSCE

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Introduce, check I.D., explain, obtain consent

1. Inform pt that you require a chaperone

2. WASH HANDS!

3. Ask pt to go behind curtain, remove garments from upper body, and sit on couch. Cover self with blanket and call out when ready.

4. Inspection

   1. With arms by sides, arms elevated with hands on head, and with hands pressed firmly on hips

   2. Inspect for:

      1. Symmetry of shape and level

      2. Shape deformities

      3. Swellings: fibrocystic changes, fibroadenoma, abscess, carcinoma

      4. Nipple inversion: congenital / cancer / duct ectasia

      5. Nipple discharge (see below)

      6. Skin changes: peau d’orange (dimpling of skin: carcinoma); eczma around nipple (Paget’s disease¹); scars (breast augmentation / other previous surgery)

      7. Indentations, tethering of swellings (malignancy)

   3. Inspect axillae for swellings and scars

5. Palpation

   1. Lie pt at 45? on couch, one hand behind head.

   2. Ask if there is and breast tenderness or lumps, and ask pt to point towards any. Palpate normal side first

   3. Palpate all 4 quadrants with flat of fingers, using rotary movement, gently compressing breast tissue against chest wall, to feel for presence of any swellings.

   4. Palpate tail of Spence with thumb and forefinger

   5. If lump is present, establish:

      1. Site – upper / lower, inner / outer

      2. Size – measure using ruler

      3. Shape – circle / irregular

      4. Consistency – firm / rubbery / stony hard / spongy soft

      5. Temperature – warm / cold

      6. Mobility – mobile / fixed / tethered

   6. Nipple: check for discharge; smear and swab for cytology and microbiology. Colours:

      1. White – milk (lactation)

      2. Yellow (exudate) – fibroadenosis, abscess

      3. Green (cellular debris) – fibroadenosis, duct ectasia

      4. Red (blood) – duct carcinoma, duct papilloma

   7. Axillae: rest pt’s right elbow in one’s right hand, and take weight of pt’s forearm. With left hand palpate anterior, medial, apical, posterior and lateral regions. Do other side.

   8. From behind: cervical and supraclavicular fossa lymph nodes, and on medial aspect of humerus

6. Repeat for other breast

7. Palpate liver, percuss lung bases, percuss spinal vertebrae

8. Thank patient, tell them they may dress. Check for any questions and concerns

9. Differential diagnosis:

   1. Inflammatory: mammary duct ectasia. Inflammation of duct, variety of causes e.g. hormonal changes in menopause, smoking, vitamin A deficiency. Green discharge, nipple inversion, redness, tenderness

   2. Traumatic

      1. Fat necrosis: hard irregular lump; history of trauma

   3. Infective

      1. Pyogenic abscess: tender lump. Pus collection due to bacterial infection

   4. Physiological

      1. Fibroadenosis: fibrocystic change, with peak incidence 35 – 50 yrs old; rare at <25 yrs. Most common cause of breast lumps in women of reproductive age. Single or multiple lumps in upper outer quadrant, that are smooth and rubbery firm, and usually bilateral. Associated with cyclical breast pain (at its worst premenstrually). Possible clear / yellow / green nipple discharge

   5. Neoplastic

      1. Fibroadenoma: commonest benign breast tumour. More in young women of 25-35. Often mistaken for cancer. Rarely painful. May be multiple. Smooth, rubbery. Usually small: 1-3cm; highly mobile (unlike breast carcinomas); in any part of breast

      2. Breast carcinoma: primary / secondary. The most prevalent cancer among women – 1/3 of all female cancers in UK. Onset age >35 yrs. Risk: nulliparity; 1^st pregnancy at >30 yrs old; early menarche; late menopause; HRT; the pill; obesity; BRCA gene (family history); not breast feeding; previous breast cancer

Firm, irregular masses. Rarely painful. Often tethered or fixed to skin. Accompanying features: nipple changes, localised oedema, lymphadenopathy, bloody discharge; symptoms of metastatic disease: breathlessness, backache, jaundice, malaise, weight loss

1.  
   1.  

      1. Phylloides tumour: rare fibroepithelial tumour

      2. Duct papilloma: benign proliferation of epithelium in major ducts. Bloody discharge, + swelling lateral to areola.

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by: Admin
Total views: 0
Word Count: 1066
Date: Fri, 22 Jan 2010 Time: 4:08 PM
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