A clinical breast examination (CBE) is a standardized physical assessment performed by a healthcare professional to screen for or evaluate breast changes. The primary purpose is the early detection of abnormalities, such as masses or skin changes, that may suggest underlying breast disease. Following a structured, sequential process ensures a thorough and reproducible assessment of the entire breast tissue area. This hands-on technique complements imaging studies, such as mammography or ultrasound, forming a comprehensive approach to breast health.
Preparing for the Examination
Preparation focuses on establishing patient comfort, privacy, and understanding. The environment must be private, and the patient should be fully gowned, allowing chest exposure while maintaining modesty. Obtaining informed consent requires a clear explanation of the examination steps and what the patient can expect.
Gathering a comprehensive medical history is integral, as current symptoms or family history influence the exam’s focus. The provider should inquire about recent changes, the timing of the last menstrual period, and any history of previous breast findings or biopsies. If a specific complaint exists, the asymptomatic breast is usually examined first to establish a baseline for comparison.
The patient is initially positioned sitting or standing upright for the visual assessment and lymph node check. This upright position allows the natural contour and symmetry of the breasts to be assessed without the flattening effect of lying down.
Visual Assessment and Upright Inspection
Visual inspection begins with the patient seated upright, arms resting comfortably at their sides, assessing overall breast symmetry, size, and shape. While some asymmetry is common, a recent, noticeable difference in contour should be noted. The skin is observed for changes in texture, color, rash, or redness.
The examiner observes the breasts in several dynamic positions to accentuate subtle changes like skin dimpling or tethering. The patient is asked to raise their arms above their head, which may reveal retraction or flattening. Next, the patient presses their hands firmly onto their hips, tensing the pectoral muscles, which can make a fixed mass more visible.
Lymph Node Assessment
During the upright phase, the examiner assesses the regional lymph nodes. The axillary nodes are palpated deeply into the armpit. The supraclavicular and infraclavicular areas, located above and below the collarbone, are also checked for enlargement or hardness. These findings provide information on lymphatic drainage pathways.
Systematic Palpation Techniques
Palpation is the most detailed part of the examination, performed with the patient lying down (supine). The patient places the arm on the side being examined above their head, and a small pillow can be positioned under the shoulder. This positioning spreads the breast tissue evenly across the chest wall, ensuring maximum contact between the examiner’s fingers and the deeper tissue.
Palpation Technique
Palpation uses the pads of the middle three fingers, which are the most sensitive for detecting subtle masses. The examiner uses small, circular motions at each point to feel the tissue. To assess all layers, three distinct pressure levels are applied: light pressure for superficial tissue, medium pressure for mid-level tissue, and deep pressure against the chest wall or ribs.
Search Patterns
A systematic search pattern ensures complete coverage of the breast tissue area, extending from the clavicle to the inframammary fold and from the sternum to the mid-axillary line. The vertical strip pattern, often called the “lawnmower” technique, is widely recommended due to its high sensitivity. This pattern involves moving the fingers up and down the chest in overlapping vertical lines.
Alternative methods, such as the concentric circles pattern or the radial spoke pattern, are also used. The time spent on palpation is linked to the exam’s sensitivity, often requiring three to five minutes per breast. The upper outer quadrant, which extends into the armpit (the Tail of Spence), requires particular attention because it is a common site for masses.
Nipple and Areola Assessment
After the general breast tissue is examined, the nipple and areola complex require specific assessment. The tissue immediately beneath the areola is palpated for masses or thickening. The nipple is gently compressed between the thumb and forefinger to check for any spontaneous or expressible discharge, noting its color and consistency if present.
Concluding the Examination and Next Steps
Once palpation of both breasts and the axillary region is complete, the physical examination concludes. The patient is given privacy to redress, and the provider communicates the assessment findings. Clear communication helps alleviate anxiety and ensures the patient understands the results.
Documentation of Findings
Any identified abnormalities, such as a mass or thickening, must be documented with specific descriptors to guide future evaluations. Findings are precisely located using the clock face method, noting the mass’s hour relative to the nipple and its distance from the areolar edge. Additional characteristics recorded include the mass’s size, shape, consistency (e.g., firm, rubbery), and mobility.
Based on the findings, the next steps are outlined. If the examination is normal, the discussion focuses on the recommended schedule for the next routine clinical exam or screening mammogram. If an abnormality is found, the patient is advised on the need for further diagnostic imaging, such as an ultrasound or mammogram.