Year 2 MBChB Clinical Skills Session Breast Examination

Transcription

1 Year 2 MBChB Clinical Skills Sessin Breast Examinatin Reviewed & ratified by Mr R Vinayagam, Breast Surgen Dr Pnawala, Cnsultant Breast Surgen Dr A Clark, GP Dr V Taylr Jnes, Cnsultant Anaesthetist Ms C Tierney, HARC

2 Learning bjectives T revise anatmy and physilgy f breast. T link anatmy and physilgy t the practical skill. T demnstrate the ability t perfrm breast examinatin and have an understanding f the cmmn abnrmalities and examinatin f apprpriate lymph ndes. Thery & anatmy Breasts are cmpsed f several different types f tissue including fatty, glandular and suspensry ligaments (Cper s ligaments) t name but a few and these different tissues will influence the texture f the breast. The nipples and the arelar tissue are cmpsed f cnnective tissue again giving it a different texture. Within the breast tissue there are between lbes which cntain milk prducing glands. The lbes in turn are cnnected t the milk duct in the nipple. The milk glands becme active twards the end f pregnancy. The arelar tissue alters clur and becmes darker during menstruatin and during pregnancy. (Increase in melanin due hrmnal changes) The surface f the breast is vascularised by the thracacrmial artery whilst the lbes are vascularised by the intercstal perfratr arteries which arise frm the internal mammary artery. The breast is innervated by the medial and lateral thracic nerves. The texture f the breast varies between smth and granular and can be tender. It will g thrugh changes in tenderness, shape, size and texture befre, during and after the menstrual cycle and pregnancy. Typically the changes f breast texture are described as feeling lumpy. The changes in texture are due t hrmnal fluctuatins in prgesterne and estrgen. It is perfectly nrmal fr wmen t have asymmetrical breasts. If breast symmetry changes it is a cause fr cncern and a reasn t have a breast examinatin. This is als the case if there is any change t the nipples. e.g. If ne becmes either inverted r everted, then this wuld be an indicatin t d a breast examinatin. All examiners wh cnduct this examinatin shuld be accmpanied by a chaperne. The chaperne must be smene wh is familiar with the prcedure. Breast examinatin is nt slely perfrmed n wmen. Men can develp enlarged breast tissue which is called gynecmastia this is caused by a hrmnal imbalance. Whilst it is nt physically harmful, it may have an aesthetic r a psychlgical impact n the patient. It shuld be nted that in rare instances it can indicate mre serius prblems. i.e. testicular cancer. Indicatins fr a breast(s) examinatin. Indicatins fr cnducting a breast examinatin may be due t the patient nticing changes n self-examinatin r attending a health check-up. These changes can include; Lumps Changes in size Tenderness excessive tenderness r ut f character Mastitis infectin f the breast tissue. Cmmn in breast feeding Discharge either nipple Skin discluratin Break in the integrity f the skin

3 Nipples changing frm being nrmally everted t inverted r vice versa Changes t the arelar tissue The abve list is nt exhaustive. Patient safety. Prcedure Fllwing yur intrductin, ask the patient if they have nted any changes in shape, size, pain r anything ut f the rdinary. Explain t the patient that they will need t remve their clthing frm the waist up and yu will have t inspect their breasts frm the frnt and lateral aspects. During inspectin the patient will need t adpt the fllwing pstures; Standing, with their arms psitined abve their head. This allws inspectin f the axilla and the axillary tail (Axillary tail This anatmical area will be discussed later n. See page 6). Hands placed n their hips and leaning frward. This allws the breast tissue t fall frward and any tissue distrtin may becme evident and may suggest a mass. Finally they are asked t lay flat, supine, n the cuch. Sme abnrmalities may becme apparent when the tissue falls against the anterir chest wall. Please nte sme patients may have t be psitined in a semi recumbent psitin - 45 if they are nt able t tlerate being in a supine psitin. Patients are asked t adpt these psitins as changes in the shape f the breast(s) may becme mre visible in in ne f the psitins; due t masses ccurring within the breast tissue causing tethering, definite change in shape / size and texture f the skin. Yu may als bserve an range peel like appearance n the surface f the skin. This is called peau d range and is caused by edema and fluid accumulatin. Assciated with tenderness and indicates inflammatry breast cancer.

4 When inspecting the breast yu shuld cnsider; Breast; size symmetry shape f breast skin clur lumps skin tethering prminent veins edema f the skin with peau d range Breast palpatin. everted, flat, r inverted (nte if recent Nipples; change r lngstanding cracking r eczema grss deviatin f the nipple bleeding r discharge Arela: bserve fr; abnrmal reddening thickening Mntgmery s tubercles nrmal fllwing pregnancy T palpate the breast tissue, if pssible, the patient shuld lay n a cuch in a supine psitin with a pillw placed behind their head. The patient s arms can be placed by their sides r alternatively behind their head. T maintain patient dignity nce yu have inspected bth breasts cver the breast that is nt being examined. Once the patient has been psitined place yurself level with the patient s chest. This is t ensure that when palpating yu are nt pushing dwn int the breast tissue, s aviding discmfrt. T palpate, use the palmar surface f yur middle three fingers, use a rtary mtin t firmly press the breast tissue against the chest wall (r alternative firm surface). At all times bserve the patient s face fr any discmfrt r distress. The breast can have a distinctly lbular texture which may be tender t palpatin. In pst-menpausal wmen the texture, size and shape can alter. E.g. breasts can shrink in size. The breasts shuld be examined in a systematic and methdical manner cvering the whle f the breast, including the arelar tissue and the nipple plus the axillary tail. If the patient has large r pendulus breasts, use ne hand as a firm surface n the breast lwer brder whilst palpating with the ther hand. The aim f palpatin is ensure that yu d nt miss any areas f breast tissue. The breast tissue is cmpressed between the surface f the chest wall and the palmer surface f the examiner's hand. Yu need t use enugh

5 pressure t cmpress the tissue against a firm surface i.e. the chest wall. The examining hand shuld remain in cntact with the breast fr the entirety f the examinatin. This ensures that nthing will be missed. There are three methds f palpatin that may be used; Lines r zig zag mvement Circles Wedges Lines The examiner places the palmer surface f their examining fingers n the breast and zigzags up and dwn the breast ensuring all tissue is palpated. This methd is the preferred methd fr self-examinatin. Circles The breast tissue is examined using a diminishing cncentric circular apprach. The examiner starts at the periphery and ends at the arela and nipple. Wedges The examiner divides the breasts int a series f segments r wedges. The breasts are examined methdically in turn frm periphery twards the nipple. The examiner traces a pattern similar t a clck face ensuring each segment is verlapped. Axillary tail The axillary tail is als referred t as the tail f Spence and is part f the upper uter quadrant f the breast. Yu must ensure that this sectin is palpated when examining the breast. T examine the axillary tail r the tail f Spence, ask the patient t rest their arms abve r behind their head. Feel the tail between thumb and fingers as it extends frm the

6 upper uter quadrant twards the axilla. If yu feel a breast lump, examine the lump. The majrity f breast lumps are fund in the upper uter quadrant. Whichever methd yu adpt, yu must be methdical in yur apprach ensuring yu d nt frget t palpate deep t the nipple, and the axillary tail. Nipple and the arelar. Cmpressing the nipple may be dne rutinely r if the patient s histry and findings indicates it shuld be cmpressed. If the patient presents with a histry f discharge, it is acceptable t ask the patient t elicit the discharge as they will prbably knw hw t d s. Alternatively, yu can check fr discharge by placing yur fre finger and thumb either side n the margins f the arelar tissue and gently cmpress and check fr discharge. If there is any discharge a sample may be taken. Be aware f Trust prtcls fr btaining, dcumenting and frwarding f specimen samples. Please nte at all times yu shuld bserve yur patient s face fr any signs f discmfrt r distress. Examinatin f the lymph ndes. A functin f the lymphatic system is t remve waste and cellular debris and the debris frm rapidly grwing tumurs will flw int the lymphatic ndes, take rt and cause nde enlargement which makes thse ndes have a hard texture and are nn-tender. The fllwing lymph ndes are palpated rutinely during a breast examinatin; Supra & infraclavicular ndes Apical (tip f the axilla) Anterir (psterir surface f anterir axillary fld) Medial (against the chest wall) Lateral (against the humerus) Psterir (anterir surface f psterir axillary fld) In yur initial explanatin t the patient yu will have indicated t them that yu will be palpating fr the lymph ndes. Please nte in health, lymph ndes are impalpable. T palpate the supraclavicular lymph ndes. Palpate alng the superir brder f the clavicle in the supraclavicular fssa nting any facial expressins f discmfrt frm the patient. Having checked the supraclavicular fssa fr any enlarged ndes, nte the size f any ndes that were palpable. Having palpated fr the supra and infraclavicular ndes nw turn t the axillary ndes. Have the patient sitting r standing ppsite yu, ask them t raise their arm and yu supprt it by taking its weight. This eliminates any muscle tensin thus making the examinatin easier and less likely t miss anything.

7 There are three methds f supprting the patient s arm whilst palpating fr the axillary ndes. 1 In this methd the examiner is using the palm f their right hand t supprt the arm at the elbw with the examining hand in the axilla palpating fr the ndes. 2 Here the patient s frearm is rested acrss the examiner s frearm. The examiner feels fr each grup f lymph ndes, whilst steadying the shulder with the ther hand. 3 An alternative is t ask the patient t rest their hand n the examiner s shulder. The examiner then methdically feels fr each grup f ndes, whilst steadying the shulder with the ther hand. As mentined earlier, in health lymph ndes are impalpable. Hwever, enlarged lymph ndes may be palpable and the size needs t be determined. Nte texture and whether they are painful when palpated r nt. Recrding findings. Yur findings shuld be written in a clear and cncise manner aided with pictures r diagrams where apprpriate. Included in all dcumentatin; Patient s name. Hspital ID number r NHS number. Date. dd/mm/yyyy Time in 24 hur clck frmat. Signature f the persn cnducting the examinatin. Print the examiner name and that f the chaperne. Fr descriptive purpses the breast has been divided int asymmetrical quadrants with dividing lines running thrugh the nipple.

8 The quadrants are; Upper uter quadrant including the axillary tail (tail f Spence.) Upper inner quadrant Lwer uter quadrant Lwer inner quadrant Identify what quadrant(s) f the breast(s) and recrd yur findings tgether with any discharge samples yu may have cllected. Please ensure yu are familiar with the relevant Trust labratry plicy prcedures. If any lumps r masses are detected then describe the; Size Psitin Brders Tenderness Any bservable skin distrtin (tethering) accmpanying the lump r mass. (The abve is nt an exhaustive list f descriptive characteristics.) This is where a diagram cmes int its wn t supprt yur recrdings. Ideally frm recrding yur findings anyne else shuld be able t read the ntes and have a gd mental mdel f what is being described and mrever its lcatin(s). D nt frget t dcument any enlarged r palpable lymph ndes in the supra and infraclavicular pints tgether with any enlarged axillary lymph ndes. What next? If any abnrmalities are fund there may be many causes and nt necessarily life changing r threatening and the subsequent treatment depends n what the cause is and the current treatment guidelines. A link t the NICE guidelines fr breast cancer referrals may be fund belw. Please nte sectin refers t urgent referral pathway and refers t nn-urgent cancer referrals. Fr ther cnditins, refer t the specific NICE guideline fr that cnditin. Glssary. Quadrants Axillary tail Ndes Artificially created znes n the breast fr descriptin purpses Als knws as The tail f Spence r Spence s tail. Als referred t as lymph ndes. See p7 fr brief descriptin f the lymphatic system. Reference Preferred methd f breast examinatin up t Medscape. It s free) (May need t sign