Wednesday, 12 March 2008

The Breast Examination

Dear Bloggers

I am a general medicine physician, not a surgeon, but it is essential to still know how to do a breast examination.

Although there are time constraints in the very busy Japanese outpatient clinics or ER departments, patients should nevertheless be asked if they have any breast problems and whether they check their breasts by themselves.

Moreover, if a female patient presents with chest pain, bone pain e.g. back pain, pneumonia or even an ovarian mass, the breasts should be examined.

There seems to be an aversion to performing breast examination especially by male junior doctors because of the age difference or even age similarity between the doctor and the patient. This should however, not prevent breast examination being performed, as it is the patient's health that is most important and not how the doctor feels. However, there are ways to make the breast examination less stressful to perform such as providing privacy by ensuring the curtains are pulled around the bedside or across the clinic examination area. Staff should be informed not to open the curtains when coming in, if indeed they actually need to come in! In fact, limit the number of people allowed to enter during the examination unless the patient has given permission. Ensure you have a nurse chaperone and that your hands are warm! Ensure that the patient is covered over whenever you are called away and when you finish the examination.

Any patient who requires a breast examination, as a doctor, you should ALWAYS take a female nurse chaperone with you so that they can observe that the examination is done correctly and that the patient and the doctor have a witness for legal purposes. Never do an examination unaccompanied.

When you eventually write your hospital notes, write down the name of the nurse chaperone as well so that you have a record of who was in attendance-- again for legal purposes.

So, how is the breast examination done?

Well, it is relatively straight forwards. First of all, GET PERMISSION FROM THE PATIENT !! You then expose the anterior chest to expose both breasts for means of comparison. Look at the skin to see if there is tethering and the classical 'peau d'orange'-- the peel of an orange, which can be a presentation of Ca breast. Look to see if there is nipple retraction. Ask the patient if the retraction, if found, is new or long standing. Some patients have naturally occurring nipple retraction, but if new, it is an ominous sign of potential malignancy.

Look at the skin colour, does the breast look inflamed? Some malignancies spreading in the surface of the breast can give a red inflamed appearance although the differential diagnosis would be an infective mastitis or even radiation exposure if there was a previous history of breast or lung cancer that had required radiotherapy.

Next, begin the palpation in the outer quadrant of the breast where the axillary tail exists. A significant number of cancers can present in this outer quadrant and can be missed by the inexperienced doctor. Palpate with both hands in each quadrant to see if the breast tissue is uniform and whether it is firm or soft. Feel to see if the breast tissue is mobile, which is normal, or fixed, the latter which is again, another sign of potential malignancy. Ask the patient if the examination is painful or not. Remember, that breast tissue changes according to the menstrual cycle with changes in female hormone levels, so tenderness may vary.

Next examine the nipple area for discharge by gently squeezing the base of the nipple. Discharge of sanguinous fluid is again another ominous sign and should alert the doctor of potential malignancy. Mucinous discharge may also be of significance.

Next, examine the axillary and cervical lymph nodes for size, consistency and mobility.

Look at the upper limbs to determine if there is any swelling of either arm and any dilatation of the veins on the arm and upper chest. Some advanced tumours can cause subclavian-axillary vein thrombosis which is a serious complication. If advanced malignancy is found, listen to the chest, palpate the bones if the patient complains of bony tenderness, perform a neurological examination e.g. brain metastases, acute cord compression, and feel the liver and other abdominal and pelvic organs. Remember that Ca breast can spread to the ovaries producing the infamous Krukenberg tumour.

If you do find anything abnormal on examination, consider asking for a surgical consultation, as such masses usually require ultrasound examination and needle aspiration or biopsy examination.

Consider checking a chest xray, and other relevant radiology depending on the examination findings plus the alkaline phosphatase, calcium and liver enzymes.

If you do not ask patients if they have breast problems then you may miss a potentially treatable problem. Some patients will not offer up that they have a breast problem unless asked. A recent patient at another hospital presented to the doctors with a breast mass that had been evolving over several years. She had not disclosed the problem to anyone and unfortunately, the malignancy was already producing end-stage problems, and hence, a curative procedure was not possible.

Just as junior doctors are not inclined to perform rectal or genital examinations, along with these, you should encourage your self to also perform breast examination whenever clinically justified because it is a part of the general physical examination that is unfortunately all to often ignored because of embarassment.

Please consider.....