INTRODUCTION TO

HISTORY AND PHYSICAL

EXAMINATION OF THE

BREAST

Dr- Tayseer Al-Tawarah MD. MRCS

Anatomy

Most common site for breast cancer

Approach to the patient

Triple assessment ❖ History and physical examination

❖ Imaging study

❖ Tissue biopsy

Common presenting symptoms

Breast lump

✓ Most common presenting symptoms

✓ Benign or malignant

✓ May be discovered incidentally during screening mammogram

✓ Ask about site, single or multiple , tenderness, symptoms during

menstrual cycle , nipple discharge

✓ fibroadenoma , breast cyst , cancer

✓ Breast abscess ( lactational Vs non – lactational )

❖Women who are breast

feeding.

❖Peripheral in the breast

❖Extension of periductal mastitis

❖Under the areola

❖Smoking

❖Fistula

Intra-operative picture of

fibroadenoma

Breast abscess

Breast pain (mastalgia)

❖ Cyclical

✓ Worse in the later half of the menstrual cycle

✓ Relived by menstruation

❖ Non cyclical

✓ Should be distinguish from chest wall pain

Skin changes

❖ Simple skin dimpling

❖ Indrawing of the skin

❖ Lymphedema of the breast

▪ Peau d’orange

▪ Infection vs malignancy

▪ Redness , hotness, tenderness not responding to antibiotic

❖ Eczema of the nipple

▪ Generalized skin disorder

▪ Paget’s disease of the nipple

▪ Dermal invasion by intraductal cancer

Peau d’orange

Paget disease of the nipple

Skin dimpling

Inflammatory breast cancer

Nipple changes

❖ Nipp le in vers io n

➢ Often benign

➢ It can be first sign of malignancy (asymmetrical )

❖ Nipp le d is c h arg e

➢ Clear or yellow, Green

➢ Bloody

• duct ectesia

• periductal mastitis

• intraductal papilloma(most common cause )

• intraductal cancer

❖ Galac to rrh oea

✓ Milky discharge from multiple ducts in both breast

✓ Drugs

✓ Hyperprolactinaemia

✓ Breast feeding

✓ Hyperplasia of Montgomery's tubercles

Nipple discharge

Gynecomastia

❖ Enlargement of male breast

❖ Often occurs in pubertal boys

Your history should include :

✓ Description and duration of sign and symptoms and

their relation to menstrual cycle and pregnancy

✓ Age

✓ Gynecological

• Nulliparity

• Age of menarche and menopause

• Pregnancy with first child , number of children ,breast feeding

✓ Drug history : OCP, TAD, Cimetidine …etc

➢ Family and personal history of breast , ovarian .

Uterine ,and colon cancer

➢ History of radiation

➢ Social history ( smoking ,obesity)

➢ Surgical history ( previous breast biopsies )

Physical examination

❖ Introduce yourself

❖ Explain to the patient

❖ Privacy

❖ Good illumination

❖ Exposure : ask the patient to undress to the waist

❖ Position : supine , sitting

Chaperon

Chaperon

Chaperon

Inspection

❖ Rest the patient hand on the thigh and inspect for

Asymmetry

Local swelling

Skin changes

• Edema

• Ulceration

• Dimpling

• Scars

Nipple changes (7 D’s)

o Deviation

o Destruction

o Duplication

o Discharge

o Displacement

o Depression ( deviation, inversion )

o Discoloration

Ask the patient to press her hand firmly on her hips

▪ Contraction of pectoral muscle

▪ Inspect again

❑ Ask the patient to raise her arm above her head

and then lean forward

▪ Expose whole breast

▪ Exacerbate skin dimpling

Palpation

Supine with her head on one pillow

Her hand under her head on the side to be

examined

With flat of the finger not palm of the hand

Ask the patient to contract and relax pectoral

muscle alternately by pushing into her hip

Nipple :

➢ gently hold it between index and thumb for

discharge

Lymph node examination

▪ Axillary

▪ Supracalvicular

▪ Cervical

Assess for ➢ Texture of both breast

➢ Tenderness

➢ Temperature

➢ Nipple discharge (color , amount )

➢ Masses

o Size

o Consistency

o Fixation

Thank you