M10.08.04 Examination Techniques

A thorough clinical breast examination is a crucial part of women’s healthcare. It can detect cancers potentially missed by mammograms and allows for demonstrating self-examination techniques to patients. However, studies reveal that examiner experience and technique significantly impact the effectiveness of the exam. Here’s a breakdown of the key aspects:

Importance of Standardized Techniques:

Clinicians are advised to adopt a more standardized approach, particularly during palpation. This includes:

• Systematic and thorough search pattern: Ensure all areas are examined meticulously.
• Varying palpation pressure: Apply light, medium, and deep pressure during the examination.
• Circular motion with fingerpads: Use a gentle, circular motion with the fingertips for optimal breast tissue assessment.

Inspection:

While inspection is routinely performed, its effectiveness in detecting breast cancer requires further investigation. Here’s what to keep in mind:

• Patient positioning: Start with the patient in a sitting position, disrobed to the waist.
• Four key views: Examine the breasts and nipples in four positions: arms at sides, arms overhead, arms pressed against hips, and leaning forward. This allows for a comprehensive assessment of symmetry, contours, and potential abnormalities.
• Asymmetry assessment: Compare the size, shape, and direction of nipples for any discrepancies.
• Skin changes: Look for changes in skin color, thickening, prominent pores, rashes, or ulceration.
• Breast development in adolescents: For young girls, assess breast development according to Tanner’s sex maturity ratings.

Table 1: Inspection Techniques and Potential Abnormalities (consider adding this table)

Note: Remember, the best time for examination is 5-7 days after menstruation due to hormonal changes affecting breast tissue.

Palpation:

Palpation is a crucial step in the exam, allowing for a deeper assessment of breast tissue consistency and potential abnormalities. Here’s a detailed breakdown:

• Patient positioning: The patient should be supine for optimal palpation.
• Palpation area: A rectangular area extending from the clavicle to the inframammary fold, and from the midsternal line to the posterior axillary line, needs thorough examination.
• Technique: Use the fingerpads of the 2nd, 3rd, and 4th fingers with slight flexion. Employ a vertical strip pattern, considered the most validated technique for detecting breast masses. Palpate in small circles at each point, applying light, medium, and deep pressure as needed.
• Examining the lateral breast: Ask the patient to roll onto the opposite hip with their hand on their forehead and shoulders pressed against the table. This flattens the lateral tissue for better examination.
• Axillary examination: Palpate the axilla for enlarged lymph nodes.

Table 2: Palpation Techniques and Potential Abnormalities (consider adding this table)

Additional Considerations:

• Feeling ribs: When pressing deeply, you might mistake a normal rib for a hard mass.
• Tail of the breast: Nodules here can be confused with enlarged axillary lymph nodes.
• Instruction for breast self-examination (BSE): Educate patients on BSE techniques during the visit. BSE, along with regular clinical examinations and mammograms, can be a powerful tool for early detection.