Bader Al-Mukhtar RCSI-MUB SC (2)

Breast history and examination

History:
Important symptoms:
1. Breast lump
2. Breast pain
3. Nipple discharge
4. Skin changes
5. Menstrual history
6. Obstetrics history
7. Risk factors

Breast lumps
o Onset: When the lump was first noticed.
o Progression: Whether the lump has remained the same size or enlarged.
o Periodicity: Whether the size of the lump changes according to the
menstrual cycle.
o Painful or painless?
o Local skin changes?
Tethering of the skin
Dimpling of the skin

Breast pain (mastalgia)

o As for pain at any other site, you should establish the site, radiation, character,
duration, severity, exacerbating factors, relieving factors, and associated
symptoms. Also ask:
o Is the pain cyclical or constantand is it related to menstruation?

Nipple discharge
o Duration
o Location: Is the discharge unilateral or bilateral?
o Content (milk or any other discharge)
o Color (e.g. clear, white, yellow, blood-stained).
o Quantity
o Spontaneous or non-spontaneous discharge?

Menstrual history
o Age of first menses. (menarche) - Early menarche (<12 years).
o Usual time between menstruations.
o Usual duration of menstruation.
o Usual quantity of menstruation heavy period
o The date of the beginning of the last menstrual period (LMP)
o Age of menopause (if applicable). - Late menopause (>55years).

1
Bader Al-Mukhtar RCSI-MUB SC (2)

o OCP use or hormone replacement therapy

Obstetric history
o Number of pregnancies and how many children has the patient had
(Nulliparity (no pregnancies))
o Age at first pregnancy (> 30 year old)
o Where the children breast-fed and, if so, for how long?

Past medical history

o Previous breast cancer or previous biopsy in the past.
o Radiation exposure

Family and drug history

o Family history of breast cancer especially first degree relatives.
o OCP and HRT

Examination

Inspection
General inspection
Patient sitting at 45 degrees, when raised her arm above her head and when pressed
her hands against her hip.

Stand in front of the patient and observe both breasts, noting:

o Symmetry
o Size
o Skin
o Scars
o Discoloration
o Ulceration
o Prominent veins.
o Dimpling or tethering of the skin.
o Swelling
An unusual finding, but one that should not be missed is the
orange peel (shed skin) appearance of peau d'orange caused by
local oedema. Seen in breast carcinoma and following breast
radiotherapy.

Nipples
o Symmetrical.
o Everted, flat, or inverted.
o Retraction.
o Scale (may indicate eczema or Paget's disease of the breast).

1
Bader Al-Mukhtar RCSI-MUB SC (2)

o Discharge.
Single duct discharge can indicate a papilloma or cancer.
Multiple duct discharge at the nipple suggests duct ectasia.

Axillae, arms, and supraclavicular fossae

Dont forget to inspect in all the maneuvers
o Ask the patient to place her hands on her head and repeat the inspection process.
Pay particular attention to any asymmetry or dimpling that is now evident.
o Visible masses, swellings, prominent veins, or skin discolouration.

Palpation
Palpation of the breast should be performed with the patient lying supine on the
couch, then the arms stretched above the head.
o Note the following:
o Tenderness
o Lumps if present then describe it fully.
o Skin changes
o Nipple discharge ask the patient to squeeze the nipple to note for any
discharge.
o increased temperature

Examining beyond the breast - Lymph nodes

o To examine the nodes at the right axilla:
o The patient should be sitting comfortably and you should stand at their
right-hand side.
o Support their right arm abducted to 90 with your right hand.
o Examine the axilla with your left hand.
o To examine the nodes at the left axilla, perform the opposite manoeuvre to
the above.
o Examine the main sets of axillary nodes including:
1. Medial
2. Lateral
3. Anterior
4. Posterior

1
Bader Al-Mukhtar RCSI-MUB SC (2)

5. Apical
o If you feel any lymph nodes, consider site, size, number, consistency, tenderness,
fixation, and overlying skin changes.
o If necessary check all the head and neck lymph nodes.