Breast history and Examination Dr AbdulQader Said Murshed Consultant General, G.I., & Laparoscoic Surgeon FRCS Glasg, FRCSI, Jordanian Board Thursday, 28/6/2018

Breast history Age Previous pregnancies Parity and breast-feeding reduce the incidence of breast cancer: a mother of five breast-fed children isless likely to have breast cancer than a nulliparous woman of the same age. Relation of symptoms to menstruation Medication Patient perception Family history

Examination Position: The patient must be undressed to the waist, resting comfortably on an examination couch with her upper body raised at 45°.

Inspection Size Symmetry Skin Duplication: accessory nipples along the mammary line from axilla to groin. visible ectopic breast tissue in the anterior axillary Fold. Ask the patient to raise her arms slowly above her head. Skin changes may then become more apparent.

Inspection (cont.) Ask the patient to press her hands against her hips to tense the pectoral muscles. This may reveal a previously invisible swelling. Inspect the axillae, arms and supraclavicular fossae.

The texture of the breast Palpation palpated with the flat of the fingers and not with the palm of the hand. Begin with the symptomless side or face the patient and feel both breasts simultaneously. The texture of the breast at the end of the second half of the menstrual cycle, the breasts may be engorged and tender. the axillary tail which lies over the anterior axillary fold. Occasionally, this part of the breast seems to be separate from the main breast.

may require bimanual examination, Palpation (cont): If you find a lump site, shape, size, surface, edge and consistency, as with a lump in any other area of the body. may require bimanual examination, Believe the patient and not your inexperienced fingers.

Relations to the structures beneath the breast Palpation (cont): Relations to skin: A fixed lesion to the skin, it has spread into the skin and cannot be moved or separated from A tethered lesion is one which is more deeply situated and distorts the fibrous septa (the ligaments of Astley Cooper) that separate the lobules of breast tissue. but the lesion remains separate from it and can be moved independently. Relations to the structures beneath the breast fixation and tethering to deep structures is less obvious. If there is a deep-seated lump, ask the patient to press her hand against her hip, which tenses the pectoral muscles.

Palpation (cont): The nipple An inverted nipple may be everted by gentle squeezing the areolar edge or by asking the patient do it for you. Nipple inversion that is easily everted is within the normal range. Unilateral inversion is more significant than bilateral inversion. Recent-onset inversion is more worrying than long-standing nipple inversion. If there is discharge, it may be possible to express fluid by gently pressing the areola (or the patient will again help). Observe whether any fluid comes from one or many duct orifices. Nipple discharge may be red, white, creamy yellow or watery

Palpation (cont): The axilla: supraclavicular fossae. neck. The axillary contents form a three-sided pyramid whose apex is in the narrow gap between the first rib and the axillary vessels. Stand on the patient’s right side. Take hold of her right elbow with your right hand and let her forearm rest on your right forearm. Persuade her to allow you to take the weight of her arm. sweep the tips of your fingers from the top of the axilla and from side to side to feel the nodes against the chest wall. To reach the apex of the axilla. move your left hand anteriorly over the anterior axillary fold and downwards into the axillary tail and behind the edge of the pectoralis major muscle. supraclavicular fossae. neck.

General examination A full examination includes checking the arms for any swelling or neurological or vascular abnormalities, and examination of the abdomen.

Triple assessment In the UK, most patients with breast problems are seen in dedicated breast clinics. The diagnostic mainstay is triple assessment, comprising: 1 history and examination; 2 imaging by mammography and/or ultrasound scanning. 3 cytology or histology. FNA cytology, and Tru-cut biopsy.