Palpation of the mammary gland – examination method
A thorough examination of the mammary glands is still an extremely important component of the early diagnosis of their diseases. Although the methodology and importance of breast examinations are reported in virtually every medical school, the current tendency to over-specialize may result in a loss of skills or, even worse, doctors will not conduct a thorough examination of the mammary glands during the examination of their patients.
If the mammary gland examination is excluded from the standard examination scheme and patients will not be referred for mammography, the possibility of early diagnosis of diseases will be missed. It can be said that this is tantamount to conducting a gynecological examination without taking Pap smears or analyzing feces without detecting hidden blood. In diseases whose early detection is so closely related to improved survival, the importance of these relatively simple methods cannot be overestimated.
Examination of the breast of the patient in an upright position
The beginning of the physical examination of the patient should be carried out in a sitting position. In the upright position, the presence of asymmetry, knots under the skin, skin or nipple contraction, and ulceration of the nipples are more noticeable. In the position with arms raised visible changes in the skin of the lower half of the mammary glands and folds under them. The contraction of the pectoralis major muscle, which occurs when the patient presses her hands on her thighs, can show skin retraction, imperceptible under other conditions.
Palpation of the mammary glands in the standing position allows you to identify the initial changes that would be more difficult to detect when viewed in the supine position. This is especially characteristic of formations located in the upper parts of the mammary gland or in the region of the axillary process, which are more noticeable when the surrounding tissues move down when the patient is in a sitting position. Examination of the supraclavicular areas and both sides of the neck in order to detect lymphadenopathy is also best carried out in the upright position of the patient.
To study the axillary region, the doctor takes the right elbow of the woman with his right hand and holds it, which helps to relax the muscles of the chest. With his left hand, the doctor palpates the lower part of the armpit, then moves towards the collarbone, the middle and upper parts of the armpit. The left axillary region is examined with the right hand while supporting the patient’s left hand with the doctor’s left hand.
If the lymph nodes are palpable, the physician should evaluate the extent of their enlargement and the size, number, and dislocation / fixation to the surrounding tissues. Dense, irregular shape, multiple lymph nodes or one another, which are tied together, as well as lymph nodes with a diameter of more than 1 cm indicate possible metastasis. In many women, especially in the presence of mild inflammatory processes on the hands (cuts, burrs, small scratches or burns), small, soft, mobile axillary lymph nodes are palpable as a result of lymphadenitis. The diameter of such lymph nodes is usually less than 1 cm, they are palpable, but not changed clinically.
A thorough examination of the skin and nipples of the mammary glands helps to identify changes indicating the presence of a malignant process. The edema of the skin of the mammary gland (in the form of an orange peel) is sometimes small, but much more often, it is longer. This symptom is more noticeable in the lower half of the mammary gland and is better detected when the patient lifts her arms up. Although such edema is usually caused by a blockage of lymphatic vessels by cells derived from deep-seated breast cancer (BC), it can also occur with a massive lesion of the axillary lymph nodes by metastasis.
The contraction of the skin and nipple is better defined when the pectoralis major muscle is reduced. Hyperemia of the skin of the breast – a terrible sign. Although it can be caused by an inflammatory process, such as periductal mastitis or abscess, it is necessary to keep in mind the inflammatory form of breast cancer. It is also important to examine the nipple to identify possible retractions or ulcerations. The ulcerations, which may initially be very small (part of the nipple), suggest an Paget’s disease. This form of breast cancer (BC), which occurs and spreads in large ducts, initially looks like nipple eczema and can capture it entirely.