What is the normal assessment of the breast?

The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information is intended for medical education, and does not create any doctor-patient relationship, and should not be used as a substitute for professional diagnosis and treatment.

By visiting this site you agree to the foregoing terms and conditions. If you do not agree to the foregoing terms and conditions, you should not enter this site.

Approach considerations

Several different palpation techniques can be used for clinical breast examination. Limited comparative data on the efficacy of these techniques are available. Key elements of a successful examination include careful observation and systematic palpation.

Observation

First, with the patient sitting up with arms at her sides, the clinician observes the shape, color, and skin characteristics of the breasts. It is important to note skin retraction, ulceration, erythema, or crusting of the nipples and to note and either establish or compare with the baseline whether the nipples are inverted, everted, or flat.

Next, the patient is asked to raise her arms over her head. The clinician should note the movement of the breast tissue as she does this and observe for any tethering of breast tissue to the chest wall. The clinician may also ask the patient to arch her back with hands on her hips, again observing for the movement of the breast tissue.

Palpation

With the patient sitting up, palpation is started.

The clinician should use the flats of the finger pads, not the tips, for enhanced sensitivity and should remain cognizant of the patient’s nipple and avoid incidental contact with his or her hand.

The examiner is responsible for evaluating all tissue between the skin and the chest wall.

Although it is possible to repeat the palpation pattern using different degrees of pressure (and therefore depth of tissue being assessed), a more efficient approach is to spiral in each position from superficial to deep, paying attention to the tissue at each level.

Palpation is begun at the medial portion of the chest wall below the clavicle and progresses down and up in a “vertical strips” pattern.

The examiner should slide from palpation position to position rather than lifting his or her hand.

Palpation is repeated on the opposite breast.

In this position, it is difficult to have confidence in the examination of the underside of the breast in full-breasted patients.

What is the normal assessment of the breast?
vertical strips and spokes of the wheel

Next, the patient is asked to lie flat with the arm of the breast being examined behind the patient's head. This stretches out the breast tissue against the chest wall and is particularly helpful in examining the lower quadrants.

The breast is palpated following a “spokes of the wheel” pattern. The areola and subareolar breast tissue in is included in the palpation pattern.

Attempting to “milk” the breast is unnecessary unless the patient has described a discharge.

Examination of associated structures

When performing a breast examination for the purpose of cancer screening, it is appropriate to include an evaluation of the supraclavicular and axillary nodal groups.

Examination of the axilla is best performed with the patient sitting upright. The patient is asked to raise her arm. The anterior wall of the axilla is formed by the pectoralis major muscle. With palm facing forward, the examiner inserts his or her hand into the axilla, just posterior to the pectoralis major and parallel to the plane of the muscle. The patient lowers her arm with the examiner’s hand in place. The examiner then rotates his or her palm perpendicular to the plane and sweeps downward. Pathologic lymph nodes may be palpated and may "pop" during the downward sweep.

Examination of the supraclavicular nodes is best performed with the patient sitting upright. Beginning medially within the supraclavicular fossa, the examiner palpates the supraclavicular fossa thoroughly to its lateral boundaries. Nodes that are hard, fixed to the underlying structures, or greater than 1 cm may be pathologic and warrant further investigation.

Documentation

If an abnormality is identified, it is important to record it accurately.

Using the nipple as the center of a clock face, any lesion is described by its clock position, distance from the nipple, and relative depth from the skin. It is useful to draw a simple diagram of the abnormalities identified.

Abnormalities should be described by their contour (linear, round, or lobulated), texture (fluctuant, soft, firm, rock hard), mobility (eg, fixed to the underlying tissue), and standard findings for inflammation, if present (warm, red, tender). It is also important to note any associated skin changes such as peau d'orange,ulceration, or new nipple inversion.

What is the normal assessment of the breast?
Peau d'orange

Documentation of a normal breast examination includes a description of symmetry, contour, and the presence of any lesions. Normal tissue is usually soft and may be finely granular. Asymmetry of breast size may be a normal variant.

What should I assess in breast?

To inspect your breasts visually, do the following: Face forward and look for puckering, dimpling, or changes in size, shape or symmetry. Check to see if your nipples are turned in (inverted). Inspect your breasts with your hands pressed down on your hips.

What features should be assessed on an inspection of the breasts?

The patient is instructed to place their hands on their hips as well as raise them above their head. This allows the examiner to assess the breasts in many positions and observe overall size, shape, symmetry, nipple size, shape, texture, and color.

How do you examine a breast?

Look at your breasts directly and in the mirror. Look for changes in skin texture, such as dimpling, puckering, indentations, or skin that looks like an orange peel. Also note the shape and outline of each breast. Check to see if the nipple turns inward.

How do I know if my breasts are normal?

See a GP if you notice any of the following changes: a change in the size, outline or shape of your breast. a change in the look or feel of the skin on your breast, such as puckering or dimpling, a rash or redness. a new lump, swelling, thickening or bumpy area in one breast or armpit that was not there before.