A systematic breast examination is vital for the early detection of breast cancer and the assessment of benign breast disease.
This examination requires high levels of sensitivity, clear communication, and strict adherence to chaperoning policies.
Before beginning, ensure the clinical environment is optimized for patient comfort and medicolegal safety:
W – Wash: Clean your hands thoroughly.
I – Introduce: State your name and role.
P – Permission & Pain: Explain the nature of the exam and obtain explicit consent. Important: Always offer a chaperone and document their name, even if the patient declines. Ask if there is any localized pain.
E – Exposure: The patient must be exposed from the waist up. Provide a clinical sheet or gown and only uncover the area being examined when necessary.
R – (Re)position: Initially, the patient should sit upright on the edge of the examination couch.
Observe the breasts with the patient in three specific positions to highlight different pathologies:
Arms by the side: Observe for symmetry, size, and skin changes.
Arms raised behind the head: This stretches the suspensory ligaments to reveal skin tethering or dimpling.
Hands pressed on hips: Ask the patient to “push in” to contract the pectoralis major muscle, which can reveal deep-seated masses.
What to look for:
Skin Changes: Erythema, dimpling (peau d’orange), or ulceration.
Nipple Changes: Inversion, discharge, or Paget’s disease (eczema-like rash).
Scars: Look for previous lumpectomy, mastectomy, or breast augmentation.
Ask the patient to lie flat with their hand behind their head on the side being examined. This “flattens” the breast tissue against the chest wall.
The Systematic Sweep
Use the flats of your middle three fingers to palpate the breast tissue. You can use a “spiral” pattern or a “grid” pattern, but you must cover all four quadrants and the axillary tail (Tail of Spence).
Lumps: If a lump is found, assess its:
Size and Shape.
Consistency (soft, firm, or stony hard).
Mobility (tethered to skin or fixed to muscle).
The Nipple: Gently compress the areola to check for discharge.
Breast pathology frequently spreads via the lymphatic system. While the patient is sitting up, support their arm and palpate:
Axillary Nodes: Apex, anterior, posterior, medial, and lateral walls.
Supraclavicular Nodes: In the supraclavicular fossa.
Infraclavicular Nodes: Just below the clavicle.
To finalize the OSCE breast assessment, state you would:
Examine the other breast: Always perform a bilateral comparison.
Examine the Liver: To check for hepatomegaly (metastatic spread).
Auscultate the Lungs: To check for pleural effusions or masses.
Refer for “Triple Assessment”: If a lump is found, state the patient needs clinical exam, imaging (Ultrasound/Mammogram), and biopsy (FNA/Core biopsy).
| Feature | Fibroadenoma | Breast Cyst | Breast Cancer |
| Age | Young (15–30) | Perimenopausal | Postmenopausal |
| Consistency | Firm, “rubbery” | Soft, fluctuant | Hard, irregular |
| Mobility | Highly mobile (“Breast mouse”) | Fairly mobile | Fixed/Tethered |
| Pain | Painless | Can be tender | Usually painless |
For a professional demonstration of the clinical technique:
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