Breast Examination -- Cetak 2010

7/24/2019 Breast Examination -- Cetak 2010

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SKILLS TRAINING MANUAL BOOK

BASIC SURGICAL SKILLS

YEAR II

BLOCK 2.5

BREAST EXAMINATION

Skills Laboratory

a!"lty o# M$%i!i&$

U&i'$rsitas Ga%(a) Ma%a

2*+*


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BREAST EXAMINATION

BLOCK 2.5

Co&trib"tor,

%r. K"&ta S$tia%(i- S.B /K0 O&k

Oncology Subdivision, Department of SurgeryFaculty of Medicine Universitas Gadjah Mada/ Dr Sardjito General !ospital

"ogya#arta

%r. Arta&to 1a)yo&o- S.B

Oncology Subdivision, Department of Surgery

Faculty of Medicine Universitas Gadjah Mada/ Dr Sardjito General !ospital

"ogya#arta

CoCo&trib"tor,

%r. Y"lia 1ar%)a&i

$ssistant of %ontent Development &eam for S#ills &rainingFaculty of Medicine, Universitas Gadjah Mada

"ogya#arta

E%"!atio&al 3$si4& R$'i$$% by

dr 'achmadya (ur !idayah"ear )) %oordinator for %linical S#ills &raining

Faculty of Medicine

Universitas Gadjah Mada


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6REACE

Medical faculty students should study and practice several clinical s#ills aspreparation for entering clinical rotation prior to becoming a certified doctor %urrently,

the medical profession compels medical students to be competent in clinical s#ills before

they directly deal *ith real patients e+periencing real life medical cases For this reason,clinical s#ills are trained as early as possible &his clinical s#ills laboratory provides

opportunity for students to study and practice the clinical s#ills on their o*n

&he topic of this manual is one of the clinical s#ills topics that constitute the maintopic of asic Surgical S#ills, *hich *ill be studied continually in bloc#s throughout

undergraduate studies &opics covered in the asic Surgical S#ills, *hich *ill be studied

in "ear )), are as follo*s-

No. Toi!s #or Cli&i!al Skills Trai&i&4 Blo!k

. Simple S#in Suturing .

0 %onception, Foetal

Gro*th and %ongenital$nomaly1

%ircumcision 2

0%hildhood1

2 reast 3+amination 4

0$dulthood1

)t is important for students to recogni5e that all topics, including those listed

above, are interrelated &herefore, students are e+pected to categori5e the topics based onthe main topics, so that continuity from one topic to another can be achieved 6e hope

that in the future, this manual for clinical s#ills training can be useful for students toimprove their s#ills, especially in physical e+amination7 and for instructors *ho are

involved in providing the trainings

"ogya#arta, February 8.8

%ontributor


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TABLE O CONTENTS

9reface

&able of %ontents

)ntroduction

Objectivesasic %oncept

$natomy of the breast

%ommon reast Masses

'is# Factors for reast %ancer

:isible Signs of reast %ancer

&echni;ue of 3+amination

&he Female reast

$namnesis 0'evie* of Specific Symptom1

9hysical 3+amination

)nspection

$+illary 3+amination 9alpation

3+amination of the nipple

&he Male reast

reast Self


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LESSON 6LAN O

BREAST EXAMINATION

A. G$&$ral Ob($!ti'$s o# Skills Trai&i&4 Y$ar II

. Students are able to e+plore data 0communication, physical, procedural,supporting e+aminations1 and dra* a conclusion from patient>s problems, the

se;uence of diagnosis possibilities as *ell as to deliver the results to the patient

Students are able to perform specific procedural actions relevant to patient>sproblems, by considering ethical aspects

B. G$&$ral Ob($!ti'$s o# Br$ast E7a8i&atio&

. 9erform anamnesis on breast complaint

9erform the breast e+amination by physician

2 Demonstrate techni;ues for breast self


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General physical e+amination including breasts + 2 : ;

)nstruction for self


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student

&he other student givecomments and corrections &he

demonstrator may as# for doubt

and difficulties

chart

? 28 mins 9ractices Students grouped to practice thee+amination

4 .8 mins rea#

Auestion andans*er

Students sharing their doubts

,difficulties and comments afterfirst practices

)f there is no ;uestion

&rainer remind the important

things

@ 28 mins 9ractices Students grouped to practice the

e+amination

E. Tools. Manual oo#

reast :est

2 reast Self 3+amination Simulation

? reast %are Flip %hart4 reast Self 3+am Form

@ $l#ohol B8C

B Gloves


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Ill"stratio& Cas$

I&tro%"!tio&

reast cancer is the most common cancer in *omen *orld*ide, accounting formore than .8C of all female malignancies )n the United States, the (ational %ancer

)nstitute estimates that . *oman of every 0appro+imately .@C1 *ill develop breast

cancer during her lifetime $mong the malignancies in *omen, breast cancer is the most

common cancer to develop and is the second most common cancer cause of death )taccounts for @C of ne* cancers in $merican *omen and .C of cancer deaths )n 888,

there *ere .?,88 ne* cases *ith ?.,88 deaths in the United States Mortality rateshave declined for *hite *omen younger than 44, probably as a result of more *idespread

use of mammography and aggressive treatment regimens, but have increased for $frican

$merican *omenOnce breast cancer has occurred in a family, the ris# for other *omen in the same

family *ill develop breast cancer is significantly higher First degree relatives, such as

sisters or daughters, have more than t*ice the ris# of developing breast cancer if the

original patients developed cancer in one breast after menopause6omen *ith a familyhistory of premenopausal breast cancer in one breast have three times the ris# )f the

original patient had postmenopausal cancer in both breasts, the first degree relatives have

more than four times the ris# First


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BASIC CONCE6TBASIC CONCE6T

A&ato8y o# t)$ br$ast

&he female breast lies against the anterior thoracic *all, e+tending from the

clavicle and nd

or 2rd

rib do*n to the @th

or Bth

rib, and from the sternum across to themida+illary line )ts surface area is generally rectangular rather than round &he breast

overlies the pectoralis major and at its inferior margin, the serratus anterior

Figure 1. The Breast and Axillae Source: Bickley L.S. dan Szilagyi P.G. Bates Guide to Physical Examination

and History Taking. 9th edition. Lippicott Williams & Wilkins.!!"

&o describe clinical findings, the breast is often divided into four ;uadrants based

on hori5ontal and vertical lines crossing at the nipple $n a+illary tail of breast tissue

e+tends to*ard the anterior a+illary fold 0see figure 1

&he normal breast consist s of glandular tissue, ducts, supporting muscular tissue,

fat, blod vessels, nerves, and lymphatics &he glandular tissue consists of .4


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components vary *ith age, the general state of nutrition, pregnancy, e+ogenous hormone

use, and other factors

Fig. 2 Fig. 3 Source: Bickley L.S. dan Szilagyi P.G. Bates Guide to Physical Examination and

History Taking. 9th edition. Lippicott Williams & Wilkins. !!"

&he blood supply to the breast is carried by the internal mammary artery &he

breast has an e+tensive net*or# of venous and lymphatic drainage Most of the lymphaticdrainage empties into the nodes in the a+illa Other nodes lie beneath the lateral margin of

the pectoralis major muscle, along the medial side of the a+illa, and in the subclaviar

region &he main lymph node chains and lymphatic drainage of the breast are sho*n in

figure ?

Fig. 4. Lymphatic drainage of the breast Source: S#artz$ %.. Textbook of Physical Examination : istory and'(amination.

)th edition. W.B. Saunders *ompany. !!


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Co88o& Br$ast Mass$s

&he three most common #inds of breast masses are fibroadenoma 0a benign

tumor1, cysts, and breast cancer &he clinical characteristics of the masses are listedbelo* 0table .1 !o*ever, any breast mass should be carefully evaluated and usually

*arrants further investigation by ultrasound, aspiration, mammography, or biopsy )deally

the breast cancer should be identified early, *hen the mass is small

+i,roadenoma

*ysts *ancer

Us"al A4$ .4


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M$&str"al 9istory a&% 6r$4&a&!y. 3arly menarche, delayed menopause,and

first live birth after age 24 or no pregnancy all raise the ris# of breast cancer t*os se+ maturity ratings 0see the appendi+ .1

Arms at Sides.

(ote the clinical features listed belo*

The appearance of the sin, including

< %olor, the redness or erythema is associated *ith infection and inflammatory

carcinoma of the breast< &hic#ening of the s#in and unusually prominent pores, *hich may accompany

lymphatic obstruction, it suggest breast cancer

Thesi!e and symmetry of the breasts. Some difference in the si5e of the breasts,

including the areolae, is common and is usually normal, as sho*n in the figure ..

The contour of the breasts. =oo# for changes such as masses, dimpling, or

flattening %ompare one side *ith the other

&he characteristics of the nipples, including si5e and shape, direction in *hich

they point, any rashes or ulceration, or any discharge.$symmetry of directions in*hich nipples point suggests an underlying cancer


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Fig. 11. Arms At &ide Source: Bickley L.S. dan Szilagyi P.G. Bates Guide to Physical Examination and


Arms ver !ead" !ands Pressed Against !ips" #eaning $or%ard.

&o bring out dimpling or retraction that may other*ise be invisible, as# the patient to

raise her arms over her head, then press her hands against her hips to contract the pectoral

muscles &his maneuver tenses the pectoralis muscles, *hich may bring out dimplingcaused by fi+ation of the breast to the underlying muscles )nspect the breast contours

carefully in each position )f the breasts are large or pendulous, it may be useful to have

the patient stand and lean for*ard, supported by the bac# of the chair or the e+aminer>shands, and allo* her breasts to hang free from the chest *all

Dimpling or retraction of the breasts in

these positions suggests an underlying

cancer6hen a cancer or its associatefibrous strands are attached to both the

s#in and the fascia overlying the pectoral

muscles, pectoral contraction can dra* thes#in in*ard, causing dimpling

Fig. 12. Arms '(er )eadSource: Bickley L.S. dan Szilagyi P.G. Bates Guideto Physical Examination and History Taking. 9th edition.

Lippicott Williams & Wilkins. !!"

Occasionally, these signs may be

associated *ith benign lesions such as

posttraumatic fat necrosis or mammaryduct ectasia, but they must al*ays be

evaluated *ith great care

Fig. 13. )ands *ressed Against )ipsSource: Bickley L.S. dan Szilagyi P.G. Bates Guideto Physical Examination and History Taking. 9th edition.



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&his position may reveal an asymmetry of

the breast or nipple not other*ise visible

'etraction of the nipple and areolasuggests an underlying cancer

Fig. 14. Leaning For+ardSource: Bickley L.S. dan Szilagyi P.G. Bates Guideto Physical Examination and History Taking. 9th edition.


? AXILLARY EXAMINATION @

&he a+illary e+amination is performed *ith the patient seated facing the e+aminer

3+amination of the a+illa is best accomplished by rela+ing the pectoral muscles &o

e+amine the right a+illa, the patient>s right forearm is supported by the e+aminer>s righthand &he tips of the fingers of the e+aminer>s left hand start lo* in the e+illa, and, as the

patient>s right arm is dra*n medially, the e+aminer advances the left hand higher into the

a+illa &his techni;ue is sho*n in figure .4 and .@ 9alpate the supraclavicular,subclavian, and a+illary region

Fig. 1 and 1!. Techni,ue for axillary examination Source: S#artz$ %.. Textbook of Physical Examination : istory and

'(amination. )th edition. W.B. Saunders *ompany. !!

&he techni;ue of using small, circular motion of the fingers riding over the ribs is

used for detecting adenopathy Freely mobile nodes 2s opposite hand

? 6AL6ATION @


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&he *omen is as#ed to lie do*n and is told that palpation of the breast is ne+t

&he e+aminer stands at the right side of the patient>s bed $lthough the e+aminer can

usually palpate each breast from the patient>s right side, it is often better *ith larges- Short 9ractice of Surgery, *enty


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A$&%i7 +

SEX MATURITY RATINGS IN GIRLS , BREASTS


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Source: Bickley L.S. dan Szilagyi P.G. Bates Guide to Physical Examination and


A$&%i7 2

Sa#$ty 6r$!a"tio& o# Br$ast E7a8i&atio& Tools

. efore using the breast e+amination tool, ma#e sure that you have cut your

finger nail

6ash your hand, and use the gloves during the e+amination

2 Do not mar# using in# pen? Use it carefully

4 Follo* the *hole procedure and correct instruction


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Breast Examination -- Cetak 2010

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