Physical Examination of the Breast

Nipple and Skin Assessment

During inspection, the clinician looks for specific signs of pathology. One such finding is an inverted nipple. While some women have naturally inverted nipples, a newly acquired inversion can be a sign of an underlying mass pulling the nipple inward.

The clinician must also look for skin changes such as redness (erythema), lesions, or edema. A specific type of edema known as peau d'orange (skin resembling an orange peel) is a significant clinical finding that may suggest malignancy.

Evaluating Nipple Discharge

If a patient reports nipple discharge, the clinician should perform a targeted assessment. This involves palpating the nipple and compressing the areola to observe the color, consistency, and spontaneity of the fluid.

Clinical Note: The characteristics of the discharge are highly diagnostic. For example, a bloody or serous discharge may be associated with an intraductal papilloma, a benign growth within the milk ducts.

Palpation of the Breast

Once inspection is complete, the clinician proceeds to palpation to detect masses and assess the texture of the tissue.

The Vertical Strip Pattern

To ensure that no part of the breast tissue is missed, the vertical strip pattern is the recommended technique. This method involves moving the fingers in parallel vertical lines across both the lateral (outer) and medial (inner) aspects of the breast. This systematic coverage ensures that the entire area, including the tail of Spence, is thoroughly evaluated.

When a mass is identified, the clinician should document its:

• Size and shape
• Consistency (e.g., soft, firm, or hard)
• Mobility (whether it is fixed to the skin or underlying muscle)

Lymph Node Assessment

A complete breast examination is not finished until the axilla (armpit) has been assessed.

Palpating the Axilla

The clinician must palpate the axilla to check for lymphadenopathy (enlarged or tender lymph nodes). Because the lymphatic system plays a major role in the spread of breast cancer, finding enlarged nodes is a critical clinical finding.

Direction of Lymph Flow

Understanding the direction of lymph flow is essential for clinical reasoning. Lymphatic drainage from the breast primarily flows toward the axillary lymph nodes. Therefore, any malignancy in the breast tissue may manifest as palpable nodes in the axillary region.

Exam Tip: When palpating the axilla, use the pads of your fingers and move them in a circular motion to feel for deep-seated nodes that may be obscured by fat or muscle.

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Summary Table: Key Clinical Findings