APGOClinicalSkillsCurriculum

TheBreastExam

AssociationofProfessorsofGynecologyandObstetrics(APGO)
UndergraduateMedicalEducationCommittee2008

TheBreastExam

TableofContents

IntendedLearningOutcomes

Description

BestPractices

Checklist

PerformanceAssessment

PracticalTips

Resources

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IntendedLearningObjectives

TheAmericanCancerSocietyrecommendsthatwomenintheir20sand30sshould
haveaclinicalbreastexam(CBE)aspartofaperiodichealthexambyahealth
professional,preferablyeverythree(3)years.Afterage40,womenshouldhavea
breastexambyahealthprofessionaleveryyear.

CBEisacomplementtomammogramsandanopportunityforwomenandtheir
doctorornursetodiscusschangesintheirbreasts,earlydetectiontesting,andfactors
inthewomanshistorythatmightmakehermorelikelytohavebreastcancer.

Thepurposeofteachingthemedicalstudenthowtoperformtheclinicalbreastexam
isto:

1. Trainthemtodetectalumporchangeintheappearanceofthebreastthat
mayindicatebreastcancer

2. Teachthemtoevaluateotherbreastconditionsthatmayrequiremedical
attention,suchasmastitis

3. Teachthemtheappropriatecommunicationskillswhenperforminga
sensitiveexam,suchasthebreastexamination,onpatients

Description

GeneralApproach/InterpersonalSkills

Thestudentshouldintroducehimorherselftothepatient,confirmthepatients
nameandhowshewantstobeaddressed.

Thestudentshouldwashhandswithsoapandwarmwateranddrywithatowelor
alcoholbasedantiseptic.Thestudentshouldinformthepatientthathe/sheis
performingabreastexam.Thisisagoodtimetoaskthepatientifshehasnoticed
anylumpsorotherproblemswithherbreasts.

Thestudentshouldbeorganizedandhavethepatientproperlydraped,i.e.cover
areasnotbeingexamined.

Thestudentshouldclosetheexaminationinanappropriatemanner.

Inspection

Askingthepatienttolowerthegown,thestudentshouldvisuallyinspectthebreasts
fromfrontandsides.

Thestudentshouldlookforsize,symmetry(somevariationisnormal),shape,
contour(flattening,masses,anddimpling),skin(color,edema,rashes,thickening,
andvenouspattern),andscars(previoussurgery,injuries).Thestudentshoulddo
theinspectionwiththepatientperformingarmmaneuvers:overhead(picture#1),
waist(picture#2),andleaningforward(picture#3).Thestudentislookingforany
retractionwhenthepatientisleaningforward,orcontractingthepectoralmuscles.

#1

#2

#3

Palpation

1.Lymphnodes

Cervicalnodes:Thesenodesarefoundalongthesidesoftheneck.

Axillarynodes:Patientinseatedpositionusingappropriatedraping
technique.Withpatientsarmatsideandexaminerliftingarmawayfrom
sidetoaccessnodes(picture#4).
Supraclavicularnodes:Thesenodesarefoundalongalineimmediately
abovetheclavicle.Thisisdonebythestudentsteppingaroundbehindthe
patient.

#4

2.Bimanualpalpationwhilepatientsitting:

Thestudentshouldperformbimanualpalpationwiththepatientinaseated
position,usingappropriatedrapingtechnique.

Thestudentshouldusetherighthandabovethelefthandbelowtopalpatetheright
breast.Studentshouldusethepadsofthefingertipstocompressthebreasttissue
betweenfingertips.Usingthistechnique,thestudentcancheckforconsistency,
nodules,masses,andtenderness,whichmightnotbefeltinsupinebreastexam.
Repeatforleftsidebystandingonpatientsleftsideandreversinghands(leftontop,
rightonbottom).

3.Completebreastspalpationwhilepatientissupine:

Thestudentshouldpulloutthefootrest,andaskthepatienttoputherarmoverhead
duringsupinepalpation.Thearmoverheadhelpstostretchthebreasttissueagainst
thechestwall.
Thestudentthenperformscompletepalpationofthebreasts.Usetheflatpartofthe
fingers(andarotarymotion)againstthechestwallusingaradialorspiralpattern
withoutmissingareas,compressingthebreasttissueagainstthechestwallinall
quadrantsofthebreast(picture#5).Studentshouldbenotingtissueconsistency,
elasticity,nodules,indurations,masses,andtenderness.

#5

Thestudentalsoperformspalpationofbreasttissue,whichcontinuesupthechest
walltotheclavicle(collarbone)andtowardstheaxilla(armpit).

Thestudentinspectsandpalpatesthenipples(picture#6),lookingforsize,shape,
inversion,rashes,ulceration,discharge,scaling,crusting,elasticity,retraction,areolar
edemaandmasses.Thestudentthenshouldgentlygraspandcompressthenipple
andareolartissuebetweenthumbandindexfinger,notingthecolorconsistencyand
quantityofanydischarge(picture#7).

#6

#7

BestPractices

Acomprehensiveliteraturereview1hasshownthatstudentslearningbreast
examinationfromstandardizedpatientsperformbetterthanstudentstaughtby
faculty(asassessedbyaclinicalexamination).Studentslearningbreastexamination
byusingsiliconemodelshavehighersensitivityfordetectingbreastlumps(as
assessedbyabilitytodetectlumpsinsiliconebreastmodels).Studentswholearn
communicationskillsfrompatientswithcancerhavebetterskillsandattitudesthan
studentslearningfromnoncancerpatients.

Thereforewerecommendthatstandardizedpatientsbeusedtoteachtheclinical
breastexaminationtomedicalstudents,incombinationwithpracticingonsilicone
models.

____________________________________________________
1

GaffanJ,DacreJ,JonesA.Educatingundergraduatemedicalstudentsaboutoncology:A

literaturereview.JClinOncol2006;24(12):19329.

Checklist

GeneralApproach/
Interpersonal/
CommunicationSkills
Properlyintroducedhimself/herself
topatient
Establishedandmaintainedrapport
withpatient
Washedhis/herhandsorprepped
withantiseptic
Usedappropriatedraping
techniques
Performedtheexaminanorganized
fashion
Madethepatientfeelcomfortable
Usedgoodnonverbalskills
Closedtheexaminanappropriate
manner
Inspection
Withpatientsitting,inspectedboth
breastsfromfrontandsides
Askedpatienttoputarmsoverhead
Askedpatienttoputarmsonher
waistandpresselbowsforward
Askedpatienttoleanforwardwith
armsoutinfront
Palpation
Withpatientsitting,palpatedthe
cervical,supraclavicularandaxillary
lymphnode
Withpatientsitting,performed
bimanualpalpationofthebreast
Withpatientsupine,performedthe
following:
Askedpatienttoputarms

overhead
Performedcompletepalpationof
thebreastwiththeflatpartofthe
fingers
Performedpalpationoftheaxillary
tail
Gentlypalpatedandexpressed
nipples

Well
Done

Needs
Improvement

Not
Done

Cannot
Recall

GlobalAssessment

Studentsoverallperformancewas:
ExcellentVeryGoodGoodFairPoor

PerformanceAssessment

Breastexaminationskillsarebestassessedthroughdirectobservationora
standardizedpatientexercise.Thechecklist,above,canbeusedforperformance
assessment.Belowisacasescenario,whichcanbeusedforastandardizedpatient
station,followedbyanexampleofapostencounternoteifdesired(modeledafter
USMLEClinicalSkillsExam).

InstructionsfortheBreastMassStation

Thisstationis30minutesinlength.Thefirst15minutesarespentinterviewingthe
patientandperforminganappropriatephysicalexam.Thelast15minutesarespent
writingapostencounternote,whichincludespertinenthistory,physicalexam
findings,differentialdiagnosis,anddiagnosticworkupplan.

Pleasenotethatstudentsareexpectedtoobtainafocusedhistory,familyhistory,
socialhistoryandmedications,andareexpectedtoperformacompletebreast
examination.Makesurestudentsdiscusstheirinitialdiagnosticimpressionand
workupplanwiththepatient.

Oncestudentsleavetheexaminationroom,theymaynotreenter.Theyareexpected
tocompletetheirnoteandgiveittothestaffwhenfinished.

CaseScenario

Thisisa15minutestation;thestaffmemberwillknockonthedoorwhenfive(5)
minutesremainandattheendofthesession.

Ms.Smithisa52yearoldfemale,whocametotheclinictodaybecauseshenoticeda
breastlumpwhiletakingashowerlastweek.
Vitalsigns:BP135/80P70/minR14/minTemp99.5F(37.5C)

Studenttasksareto:
1. Obtainafocusedhistory

2. Performarelevantphysicalexamination

3. Discussinitialdiagnosticimpressionandworkupplanwiththepatient

4. Afterleavingtheroom,completepatientnoteontheformprovided

PostEncounterNote

History:Includesignificantpositivesandnegativesfromhistoryofthepresent
illness,pastmedicalhistory,reviewofsystems,socialhistory,andfamilyhistory.
HPI:Location,howwasitnoted,howlongpresent,hasitchangedinsize,doesit
changewithmenstrualcycle,anynippledischarge?
PMHx:Breastdiseaseorcancer,ageatmenarche,ageatfirstpregnancy,menopause
status?
PSHX:Breastbiopsies?
Social:Smoking,alcoholuse,exercise?
FamilyHx:Breastorovariancancer
Medications:OCPsorhormones

PhysicalExamination:Indicateonlypertinentpositiveornegativefindingsrelated
tothepatientschiefcomplaint.
Patientsweight
Breastexamfindingsasperchecklist

DifferentialDiagnoses:With1beingthe DiagnosticWorkup:Listimmediate
plans(upto5)forfurtherdiagnostic
mostlikely,listupto5potentialor
workup:
possiblediagnosesforthispatients
presentation(inmanycases,fewerthan5

diagnosesarelikely):

1.Mammogram
1.Nomassdetected
2.Possibleultrasound
2.Fibrocysticchanges
3.Ifmass,biopsy
3.Carcinoma
4.Ifnomass,closefollowup
4.
5.
5.

PracticalTips

Wesuggestthatthebreastexaminationbeintroducedtothestudentsduringthefirst
twoyearsofmedicalschoolintheformofdidactics,practiceonmodelsanda
standardizedpatientexercise(SP).TheSPmayberepeatedduringtheclinicalyears.
Theperformanceassessmentmayoccuraspartofanobjectivestructuredclinical
examinationattheendoftheobstetricsandgynecologyclerkshiporattheendofthe
thirdyear.

Resources

Textbook

BatesGuidetoPhysicalExamination&History.SeventhEdition.ByLynnS.Bickley,
RobertA.Hoekelman,BarbaraBates.Chapter10;TheBreastsandAxillae,pages333
353.

Models
1.http://www.mammacare.com/
2.http://www.globaltechnologies.net/ShopSite/product252.html
3.http://cancercontrol.cancer.gov/cgibin/sbir_ptitle_result.asp?GNumber=
R44CA7130002
4.http://www.adamrouilly.co.uk/products.php?catid=53

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