​Optimal Patient Gowning/Positioning

• Patient should be provided privacy to change into an open-front gown, with a large drape or sheet to assist with appropriate coverage.
• Breasts should only be exposed as necessary. For instance, both are required to be visualized for symmetry, but when examining the right breast, the left breast should be covered for patient comfort.
• Examine the patient first in a seated position, and then in the supine position.

Exam methods

• Breast inspection
  • With the patient seated and arms at sides, visualize both breasts noting the skin color, any rashes or lesions, skin thickness, size, and symmetry. In males, gynecomastia may be identified.
  • Observe breast contour, including dimpling, masses, or flattening.
  • Inspect the nipples and areolae for discharge, size, shape, inversion, or lesions.
  • Ask the patient to raise their arms over their head, place their hands on their hips, and lean forward to observe for any dimpling or change in contour.

• Breast palpation
  • Examine the patient in a supine position with the ipsilateral arm raised to rest on the forehead or behind the patient’s head.
  • A vertical strip pattern is the best technique for evaluating breast masses. Palpate using the pads of the second, third, and fourth fingers, keeping the fingers slightly flexed, in small concentric circles, applying ascending pressure to each area. Starting at the axilla, work in a vertical pattern, moving inward to the midline. Once the nipple line is reached, the patient should place the ipsilateral hand on that same shoulder with the elbow at the level of the shoulder for best positioning, as the assessment continues to the medial breast. It is important to be systematic.
  • The examiner should note the consistency of the tissues, tenderness, lesions, or nodules. Location of any nodules or masses should be described in a clock pattern or quadrant.
  • Palpate each nipple, noting the color, consistency, and quantity of any discharge and exactly where it appears.
• Axilla inspection and palpation
  • While patient is supine, inspect the axilla for excoriation, lesions, or rashes.
  • Palpate for masses, nodules, and lymphadenopathy. The patient’s arm should be relaxed at his/her side, and the examiner cups their his/her fingers, reaching as far into the axilla as possible, reaching behind the pectoral muscle to palpate the lymph nodes. To do so, use your right hand to examine the left axilla, and the left hand to examine the patient’s right. The patient should be advised that this examination may be uncomfortable.

PEARLS

• Female breasts contain hormonally sensitive tissue, with uneven texture known as physiologic nodularity. Male breasts lack the development of ductal branching and lobules, making it difficult to distinguish from pectoral muscle tissue.
• Palpating the breast tissue while the patient is supine is helpful as this flattens ou tthe tissue.
• While performing the breast assessment, teach and reinforce the importance of breast self-exams. Remind the patient of the importance of being familiar with their anatomy and what feels “normal” to them, and to see their medical provider if any abnormalities develop.