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Breast examination frequently appears in OSCEs. You’ll be expected to pick up the relevant signs using your examination skills. This breast examination OSCE guide provides a clear step by step approach to examining the breast. Check out the breast examination OSCE mark scheme here.

Introduction

Wash hands

Introduce yourself

Confirm patient details – name / DOB

 

Explain examination:

“Today I’ve been asked to perform a breast examination, do you understand what this will involve?”

“The examination will involve me first inspecting the breasts, then placing a hand on the breasts to assess the breast tissue. Finally I will examine the glands of your neck and armpit.”

 

Explain the need for a chaperone:

“One of the female ward staff members will be present throughout the examination, acting as a chaperone, is this ok?”

 

Check understanding:

“Does everything I’ve said make sense?

“Do you feel you understand what the examination will involve?”

“Do you have any questions?”

 

Gain consent:

“Are you happy for me to carry out the breast examination?”

 

Ask the patient to undress down to the waist behind the curtain – provide blanket to cover

If the patient has presented due to concerns about a lump, ask the patient about the location of the lump.

General inspection

Ask the patient to sit upright, ideally on the side of the bed.

Ask the patient to uncover the breasts at this point.

Note any obvious masses, scars or asymmetry.

  • General Inspection

Close inspection

Arms by side

Position the patient with their hands on their thighs relaxed.

Scars – small scars (lumpectomy) / large diagonal scars (mastectomy)

Asymmetry – healthy breasts are often asymmetrical

Masses – note the size and position- look for overlying skin changes

 

Skin changes:

  • Erythema – infection / superficial malignancy
  • Puckering – may indicate an underlying malignant mass
  • Peau d’orange – cutaneous oedema – inflammatory breast cancer


Nipple changes:

  • Retraction – congenital / underlying tumour / ductal ectasia
  • Discharge – may indicate infection or malignancy
  • Scale – may indicate Eczema or Paget’s disease
 
 
  • General Inspection

Hands on hips

Ask patient to place hands on their hips and push inwards (to tense pectoralis major).

Repeat inspection.

Observe for any masses once again:

  • If a mass is noted, observe to see if the mass moves with the pectoralis muscle
  • This is known as tethering and suggests invasive malignancy
  • Inspect breast whilst patient contracts their pectoralis muscles.
 

Arms above head

Ask patient to place both hands behind their head.

Inspect the breast tissue for any evidence of:

  • Masses
  • Asymmetry
  • Dimpling / puckering
  • Inspect breasts and axillae with the patient's hands behind their head.

Ask the patient to now lean forwards, keeping their hands behind their head.

Repeat inspection of the breast tissue as above.

This position will exacerbate any skin dimpling / puckering which may relate to an underlying mass.

  • Inspect breasts whilst pendulous, looking for asymmetry and puckering.

Palpation

Breast

Examine the “normal” asymptomatic breast first. Ensure to warm your hands before touching the patient.

Position the patient laid on the bed at a 45 degree angle.

Ask the patient to place their hand on the side being examined behind their head.

Use the flat of your fingers to compress the breast tissue against the chest wall, feeling for any masses.

 

Use a systematic approach to ensure all areas of the breast are examined:

  • Clock face method – examine each “hour” of the breast
  • Spiral method – start at the nipple and work outwards in a concentric circular motion

 

If a mass is detected, ensure you complete a thorough examination of the remaining breast tissue before examining the mass further.

See the “How to examine a breast lump” section below for further details.

  • Position patient supine, with the hand on the side you're examining behind their head.

Axillary tail

Palpate the axillary tail of breast tissue:

  • Breast tissue often extends into the axilla and is known as the axillary tail
  • The majority of breast cancers develop in the upper outer quadrant so it’s essential this area is examined thoroughly
  • Palpate the axillary tail of breast tissue.

Nipple

If the patient reports having nipple discharge, ask them to squeeze the nipple to demonstrate this.

  • Yellow / green discharge  – suggestive of infection
  • Bloody discharge – more suspicious of malignancy – e.g. papilloma 

Repeat palpation on the other breast, asking the patient to place their alternate hand behind their head.

  • Ask the patient to palpate the nipple to assess for any discharge.

How to examine a breast lump

If a mass is detected assess the following characteristics, which you’ll need to summarise back to the examiner.

Position 

  • Which quadrant of the breast is the mass located within? e.g. upper outer quadrant
  • Using the clock face metaphor, what “hour” on the clock is the mass located at? e.g. 2 o’clock
  • How far away from the nipple is the mass located? e.g. 4cm

 

Size and shape

  • What are the approximate dimensions of the mass? e.g. 2cm x 3 cm
  • What shape is the mass? – e.g. spherical / elongated / irregular

 

Consistency

What is the consistency of the mass on palpation?

  • Smooth / firm / stony / rubbery

 

Overlying skin changes

Are there any changes to the skin surrounding / overlying the mass? –  e.g. erythema / puckering

 

Mobility

Assess the degree of mobility the mass has:

  • Does it move freely?
  • Does it move with the overlying skin?
  • Does it move with pectoral contraction?

 

Fluctuance

Hold the mass by its sides then apply pressure with another finger to the centre of the mass.

If the mass is fluid filled (e.g. cyst) then you should feel the sides bulging outwards.

  • Palpate the location, consistency and borders of the mass.

Axilla

1. Have the patient sit on the edge of the bed facing you.

2. Support the patient’s arm on the side being examined with your forearm.

3. If you’re examining the right axilla, use your right arm to support the patient’s (vice versa for left).

 

4. Palpate the axilla with your free hand, ensuring to cover all areas of the axilla:

  • Medial / lateral / anterior / posterior walls
  • Apex of the axilla

 

5. Note any lymphadenopathy – malignancy / infection

  • Palpate the axillary lymph nodes to detect any lymphadenopathy.

Other lymph nodes

Finally perform a general lymph node examination of the following areas:

  • Cervical
  • Supraclavicular
  • Infraclavicular
  • Parasternal
  • Palpate infraclavicular lymph nodes

To complete the examination

Thank patient

Cover patient up with a blanket / sheet

Leave the room and allow them time to re-dress

Wash hands

Summarise findings

.

Suggest further assessments and investigations

  • Ultrasound
  • Mammography
  • Biopsy (fine needle aspiration / core biopsy) – to determine histology
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