A breast examination by the doctor includes a visual exam as well as a physical palpation of the breasts.
Visual Examination of the Breasts
At this point a doctor may introduce a large mirror. This is for your education, so that you can observe what your doctor observes. It can be used to point out any unusual findings during the breast exam. (However, problematic findings should be discussed after you are dressed.) The doctor should encourage you to perform a regular breast self exam at home with a wall mirror and a large hand mirror.
The first thing we want to do is to uncover both breasts completely and seated with weight evenly distributed. Usually, shoulders will then be level. Your doctor should simply ask you to lower the gown to your waist. Now the doctor, standing in front of you, will visually examine your breasts with the patient in the seated position, looking side to side, and if necessary (as in the case of a woman with large or pendulous breasts), they may ask you to raise or lift your breasts with your hands so that they may see underneath. If there is any nipple discharge, lesions on your breasts or if you are a nursing mother, then they should glove before palpating. If there are any cuts, open sores, etc. on the doctors hands, they need to protect you from this. The following are some of the things we are looking for during the visual exam - symmetry, masses, lesions, skin changes and dimpling.
Now, you should be asked to put your hands on your hips and to raise your shoulders, squeezing shoulder and chest muscles, or shrug or curl the shoulders forward. The doctor visually examines the breasts looking side to side, looking at the various aspects of the breast tissue. Now the doctor visually examines the breasts with you leaning forward. Then they should ask you to raise your arms above your head slowly. The doctor should be visually examining the breast tissue, noticing the movement and whether it moves as a whole. If anything tugs or dimples, this could indicate a problem
Physical Breast Examination
Now the physical examination of the breast tissue begins. The key elements of the palpation of the breast, for the doctor and for self breast examination, are:
- Be thorough and don't miss anything. Cover the entire breast including the tail (the area of skin that fans up to shoulder.)
- Palpate in a methodical path using the pads of 3 fingers (or 2, depending on size of fingers) in dime-size circular motions with 3 degrees of pressure (light, medium, and deep). Some findings are only evident with a particular degree of pressure from the examiner.
- The fingers should maintain contact with the surface of the skin, and proper spacing between palpations should be used. This will help to assure that no area is missed.
Following the head-to-toe path of the body, the seated exam begins by palpating the supraclavicular and infraclavicular lymph nodes located above and below the clavicle (collar bone). So that you are not unnecessarily exposed, be advised that you may raise your gown up to just below the collarbone (either tucking it under your arms, or putting your arms into the sleeves). The doctor should let you know that you are beginning the physical exam and explain what she/he is doing.
The technique they will use is the same technique used for self breast examination so I will describe it in detail. This palpation technique should be used throughout the breast exam. With the pads or flats (the entire area from the last joint to the end of the finger) of the 3 middle fingers (or 2, depending on hand size) apply a light, medium, then deep pressure in dime-size circles (imagine tracing the outline of a dime with your middle finger). The light pressure is very gentle, enough to move the skin without disturbing the tissue underneath. The deep pressure should be deep enough to reach the chest wall. The pads are the most sensitive part of the fingers, so the tips should not be used. Holding your hands straight or even bowed back a little will help keep your fingers flat. After each palpation, drag fingers to the next location, allowing them to overlap the areas palpated. A good technique for dragging after each circular palpation, and to ensure proper spacing, is to step over about 2 cm (or about 1 inch) with the leading finger, then slide the other two fingers over, being careful to keep the 3 fingers together for the next palpation. Be sure not to lift all 3 fingers from the surface as you don't want to lose your place. The doctor should begin palpating supraclavicular and infraclavicular lymph nodes.
Palpation of the Breasts
Now the doctor should palpate the right breast and axilla. (It doesn't matter which breast is examined first, as long as the breasts are examined one at a time, and that both breasts of patient are to be examined.) The doctor may want to use cornstarch powder (baby powder) dispensed from an individual container so that there fingers glide more easily. You can also use cornstarch to make self-exam more comfortable. So that you are not unnecessarily exposed, you may cover your left breast. Expose only what is necessary to examine at the time.You should be asked to either place your right hand on your hip, or your arm over your shoulder. Using the 3 degrees of pressure and the pads of their 2 - 3 fingers, the doctor begins to palpate the breast tissue starting at the top of the tail. The breast tissue goes up this high and is more than what fits into the bra cup; this should also be a part of your monthly self-exam. Never losing contact with the breast tissue, the doctor drags her/his fingers to the next location; overlapping the areas palpated. In horizontal strips, they palpate the upper boundary of breast tissue, starting near the collarbone, back and forth from the sternum to the axilla, working down to the beginning of the breast fullness, the part of the breast that fits into the bra cup.