The Breast. Palpation is best performed when the breast tissue is flattened. The patient should be supine. Plan to palpate a rectangular area extending from the clavicle to the inframammary fold or bra line, and from the midster-nal line to the posterior axillary line and well into the axilla for the tail of the breast.
A thorough examination will take 3 minutes for each breast. Use the finger-pads of the 2nd, 3rd, and 4th fingers, keeping the fingers slightly flexed. It is important to be systematic. Although a circular or wedge pattern can be used, the vertical strip pattern is currently the best validated technique for detecting breast masses. Palpate in small, concentric circles at each examining point, if possible applying light, medium, and deep pressure. You will need to press When pressing deeply on the more firmly to reach the deeper tissues of a large breast. Your examination breast, you may mistake a normal should cover the entire breast, including the periphery, tail, and axilla. rib for a hard breast mass.
■ To examine the lateral portion of the breast, ask the patient to roll onto the opposite hip, placing her hand on her forehead but keeping the shoulders pressed against the bed or examining table. This flattens the lateral breast tissue. Begin palpation in the axilla, moving in a straight line down to the bra line, then move the fingers medially and palpate in a vertical strip up the chest to the clavicle. Continue in vertical overlapping strips until you reach the nipple, then reposition the patient to flatten the medial portion of the breast.
Nodules in the tail of the breast are sometimes mistaken for enlarged axillary lymph nodes (and vice versa).
■ To examine the medial portion of the breast, ask the patient to lie with her shoulders flat against the bed or examining table, placing her hand at her neck and lifting up her elbow until it is even with her shoulder. Palpate in a straight line down from the nipple to the bra line, then back to the clavicle, continuing in vertical overlapping strips to the midsternum.
Examine the breast tissue carefully for:
■ Consistency of the tissues. Normal consistency varies widely, depending in part on the relative proportions of firmer glandular tissue and soft fat. Physiologic nodularity may be present, increasing before menses. There may be a firm transverse ridge of compressed tissue along the lower mar-
Tender cords suggest mammary duct ectasia, a benign but sometimes painful condition of dilated ducts with surrounding inflamma-
gin of the breast, especially in large breasts. This is the normal inframam-mary ridge, not a tumor.
■ Tenderness, as in premenstrual fullness
■ Nodules. Palpate carefully for any lump or mass that is qualitatively different from or larger than the rest of the breast tissue. This is sometimes called a dominant mass and may reflect a pathologic change that requires evaluation by mammogram, aspiration, or biopsy. Assess and describe the characteristics of any nodule:
Location—by quadrant or clock, with centimeters from the nipple
Shape—round or cystic, disclike, or irregular in contour Consistency—soft, firm, or hard tion, sometimes with associated masses.
See Table 8-2, Common Breast Masses (p. 315).
Hard, irregular, poorly circumscribed nodules, fixed to the skin or underlying tissues, strongly suggest cancer.
Delimitation—well circumscribed or not Tenderness
Mobility—in relation to the skin, pectoral fascia, and chest wall. Gently move the breast near the mass and watch for dimpling.
Cysts, inflamed areas, some cancers may be tender
Next, try to move the mass itself while the patient relaxes her arm and then while she presses her hand against her hip.
A mobile mass that becomes fixed when the arm relaxes is attached to the ribs and intercostal muscles; if fixed when the hand is pressed against the hip, it is attached to the pectoral fascia.
The Nipple. Palpate each nipple, noting its elasticity.
Thickening of the nipple and loss of elasticity suggest an underlying cancer.
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