1. HistoryCA risk factors
2. Setup
3. Inspect: wholebreastsskinnipplesmaneuvers
4. Palpate: nodesquadrantsaxillarytailsnipples

History

• Dischargebleeding.
• Tenderness (inflammatoryeg abscess).
• Location: quadrantsproximity to nippleunilateral vs. bilateral 
• Timing: spread of masses.
• Timing: midcycle tenderness (fibrocystic change).
• Currently breast feeding (mastitis).

CA risk factors

• A History ALONE:
  • Age: older
  • History: familyprior dz
  • Abortion
  • Late menopause
  • Obese
  • Nulliparity
  • Early menarche

Setup

• Pt removes upper body clothingin gownsitting up.
• Briefly describe examination to pt.
• Pt. removes gown.
• Pt. relaxes arms by side.

Inspect: whole breasts

• Symmetry.
• Swelling.
• Visible masses.

Inspect: skin

• Dimpling.
• Peau d'orange (CA).
• Skin retraction.
• Veins: bilateral vs. unilateral (CA).

Inspect: nipples

• Nipple positioninversionretraction (fibrosisCAnormal).
• Redbleeding (Paget's dz of nipple).
• Discharge.

Inspect: maneuvers

• Pt. raises arms above head. Look for:
  • Change in a mass's relative position.
  • Nipple or skin tethering.
• Examine axillae while pt's arms are raised. 
• Pt. pushes hands down on hips. Look for:
  • Dimpling.
  • Fixation.
• Large breasts: pt. leans forwardhands on knees.

Palpate: nodes

• Axillary nodes.
• Supraclavicular nodes.
• See Hemolymphoid Examination.
• If exam normal so fartell pt.

Palpate: quadrants

• Pt. lies down.
• Pt. places hands behind head.
• Ask if any part tender before palpate (inflammatory).
• If sores visiblewear gloves.
• Use fingerpads of middle 3 fingers.
• Press breast against chest wall by rolling fingers in smallcircularmotions.
• Press lightly for superficial layersmedium pressure for middle layerfirmer pressure for deepest layers.
• Start at sternoclavicular junction.
• Move in overlapping vertical stripsuntil all 4 breast quadrants arecovered.
• See Examining A Mass Reference.

Palpate: axillary tails

• Pt. places arms above head.
• Palpate tail between fingers and thumb.

Palpate: nipples

• Palpate around areola.
• Palpate depression under nipple.
• Gently press nipple between thumbindex fingernoting discharge.
• See Examining A Mass Reference.
• See Breast Lump Reference.

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