How to Perform a Breast Examination - Clinical Skills Revision - Dr Gill

hello and welcome to another clinical skills uh video my name is james gill and i'm one of their lecturers at warren medical school and as you see things are ever so slightly different today the reason being twofold first off the medical school is open again excellent the other reason is that i did film my latest examination video and unfortunately the introduction was out of focus so i'm currently decamped in one of the offices that stays at the medical school to try and film uh or refilm this introduction a pain in the neck but i think it's important so in terms of today as you can see we've been visited yet again by the limbs and things fairy and today we have one of their new dark skin tone clinical skills trainers i think having clinical skills bringing variation to the practices that we teach our students is exceptionally important and this isn't so much about representation as it is about understanding the differences we have between people the vast majority of um clinical pictures even in you know our standard textbooks are on light-skinned individuals and that does cause us quite a bit of difficulty when it comes to examining people with different skin tones thankfully now let's just say we are embracing the need for diversity both in teaching materials and in the examinations and the examples that we provide to students so having this variation in skin tone i think is exceptionally important in building a more inclusive medical education experience so that's the background to these uh new training models but there is a slight wrinkle here still because um coronavirus is still doing what it does i'm still unable to ideally film a proper examination now it sounds a bit of a a question why does that matter if you've got another of these trainers well these trainers can be examined on their own on a bench using the torso that they come with in the box however they can be used in a much more effective manner and that's by having them worn by somebody in order to act as you know the trainee patient now that sounds a bit surprising but when we think about the abdominal examination a lot of that is with the patient lying flat on the bed thus we can use mock abdominal trainers when it comes to the rectal examination and the vaginal examination once we have positioned the patient correctly there's not really a significant amount more adjustment that is needed from the patient however as we're going to see here there's quite a lot of changes that are needed in how the patient is sitting and positioning themselves so as a simple example to that when we initiate a breast examination we get the patient to remove their tops and things and sit upright on the bed and we would obsess this a patient to see if we can see any changes in skin tone contour that small changes in skin contour which may be enhanced by different lighting might allow us to assess before we actually lay hands on the patient where we're likely to find potential pathologies unfortunately this trainer doesn't allow for that similarly it doesn't allow for things like getting the patient to press down on their hips to engage their pectoral muscles or getting them to put their arms above their head or even change the their position when lying down for that part of the examination thus this trainer will allow you to examine and train students effectively with that understanding in mind however as i say given covid is what it is i'm unable to do that adequately at the moment so what i'd be really interested in is if you guys give me a comment down below to say whether or not you think it will be worthwhile for us to refilm these examinations or particularly this one when we are able to interact with students and things like that and film them in a non-covered ppe world because i can assure you the masks and gowns and things do not make for an easy examination i have tried so whilst you're down in the comments section little segue here i'd be really grateful if you could like the video because we all must obey the youtube algorithm and also subscribe to the channel that way you'll be able to interact with us on the community's feed and say what's working well for yourselves in terms of these videos but also what we could do to improve things and we do take that feedback on board when we're planning our next video and part of that is over the next few weeks we're going to be attempting to look at the specifics of some of the clinical signs so for example one of the first will be taking a blood pressure and the science behind that so with that in mind i will direct you to one of the earlier videos that we've done explaining a lot about the medicine the science the biology of the breast examination and how the breast is structured if i get my left and rights correct then we should get a pop out somewhere up there which will link you to that video i personally feel that the breast examination is one of the most important examinations that we do now surely you're going to ask are all examinations not equally important now i may do a cranial nerve examination once a month at the moment however it's not unsurprising that we need to do a breast examination probably you know several times a day maybe once a week the reason being is we've been able to effectively educate patients about the need to self-examine having people check their own breasts and thus we are finding a much greater incidence of breast lumps now as you'll see in a minute finding a breast lump is not necessarily a problem there are lots of benign breast lumps that people can find however having this knowledge out in the community and people are doing so well at coming forward when they found a lump when something is worrying them which is tremendous it does mean that i'm doing breast exams quite often and i am so so pleased that patients are coming in with their worries and we're finding these things and hopefully it means those few few patients that do have breast cancer we understand that one in nine people in the uk are at risk of getting breast cancer in their lifetime that we'll catch things early so we'll hopefully be able to address that problem address that cancer without it becoming a much more significant problem for them so in that in mind i think this is an examination where we're going to be able to save lives if only by having people engage with what breasts feel like and what we might be able to find during examination and reiterating how important this examination is so with that in mind let's unpack the box see what limbs and things has provided us with and more importantly transfer back to the previous video that we shot so if we have a look at the pathology that limbs and things has included in the box we've got an example of large fibrocystic disease approximately six centimeters across this will be easily palpable is having a multi-lobular surface but that surface should be relatively smooth so these are benign findings on the breast they tend to be rubbery and often found in both breasts and crucially change across the menstrual period it's often appropriate to reassure a patient who's attended with what appears to be fibrocystic changes particularly if they've been there for a matter of days to weeks however if we did find that the mass continued on after menstruation then it would be entirely appropriate and correct to ensure that the patient was seen in the breast clinic and the nature of the lump investigated then we have a fibroadenoma this is probably one of my favorite pieces of the trainer here the fibroadenoma is known as a breast mouse because the way that it moves around in the breast tissue when examining it as it's sitting in its own pocket within the breast and the way that the team have managed to recreate that sensation when you're examining these mobile lumps is absolutely fabulous it's a really good representation of what you come across breast cancer which is obviously the major concern on anybody having a breast examination is uncommon in the whole when it comes to the causes of breast lumps by contrast the fibre adenoma that we have here is smooth mobile and discreet it feels very rubbery in nature and in fact it's called a breast mouse due to the way that it will move around under the skin in this discrete area that mobility is because this is normally found as a benign overgrowth of the ducts in the breast allowing space for the fibrous adenoma to move around cysts these are smooth often fluid filled sacs cysts can be found anywhere in the body and are smooth fluid filled sacs but when present in the breast tends to be seen more commonly between the years of 35 to 55 years of age often this is what people will present to a gp surgery with saying that they've found a lump in the breast they will change potentially across the month a little bit like fibrocystic changes they can be soft and fluctuant because they're fluid filled when the pressure in the sac is low conversely they could be painful if the pressure and the fluid level in that sac is high cysts can occur in clusters which can be problematic for a clinical examination as it may be difficult to determine what is a cystic problem and what is actually a cancer this is why the vast majority of people who are found to have a lump in their breast will be sent to the breast clinic for investigation again like the fibrocystic problem breast cysts the vast majority are benign but there's always going to be things we would look for that would cause caution once in the breast clinic it's quite common that cysts are drained so they're not painful but if anything can be palpated after the drainage has been performed or similarly if it returns then we'd have an increased level of suspicion then we have the breast cancers themselves limbs and things has provided us with three examples a large mass approximately three centimeters in size a smaller mass two centimeters in size and then a one centimeter breast cancer if we compare the cancers to fibrocystic disease we can see the differences while the fibrocystic disease is large will feel rubbery and will have multiple lobes to it the breast cancer is more irregular in nature by comparison the breast cancers will normally feel firm or hard fibrocystic disease can often be difficult to determine the difference between the surrounding breast tissue and the fibrocystic disease when you come across a firm hard cancer it's very evident within the breast tissue as a rule of thumb often when you come across a solid breast cancer the tissue feels quite different from the surrounding breast with the cancer often being as you can see here irregular hard and or firm and is often immobile within the breast tissue i.e you can't move it around when it comes to examining the breast we must also look beyond the breast to where the lymphatics of the breast drain and as a result of this we can often find metastatic spread in the skin under the armpits across the chest wall or perhaps even higher up in the neck as a result of this limbs and things has provided a series of lymph nodes which can be installed into the trainer to enable students to assess form potential metastatic spread via the lymphatic system the lymph nodes can be inserted into pockets which would then go into the axilla for demonstration purposes when it comes to utilizing the breasts the back plates can be removed giving access to the breast tissue whereupon cancers can be placed at various locations in the breast before being put back on in terms of utilizing the breast model the back plates can be removed and as we can see there are holes on the actual chest wall and on the breasts themselves this allows cancers to be installed on the breast and placed back into the unit for examination by students any swellings that we do find can be assessed with the mnemonic space spit that being the size the position any attachments the consistency and what are the edges we also want to assess what the surface is like if there is any pulsation if there's any inflammation and crucially can it trans illuminate suggesting fluid so today we've got the final part of the quartet that makes up our um sensitive examinations we've done the rectal examination we've done the male genital examination we've done the female genital examination and now we're going to be doing the breast examination we've done really well with the other videos having a balance between having open comments and also having them held for moderation and given that we're dealing with the breast examination today we're going to do the same again so please feel free to put all the appropriate comments down below but note that they will be held so there'll be a brief delay before they go live i'm sure you understand and thank you for that from my perspective doing a review on how to do the breast examination is exceptionally important one in nine people in the uk will end up with breast cancers and as a result the more that we can do to reassure people about going for breast examinations the better similarly if people watching this at home pick up information on how to do the breast exams themselves then all the better breast cancer whilst very common if caught early is exceptionally treatable hence the huge importance that we place on doing the breast examinations appropriately along with the other intimate examinations in the first years of medical school [Music] in order to do the breast examination appropriately we need to get adequate consent so that will involve explain the patient we're going to get them to disrobe and sit bare chested on the table when we do that we're going to get them to do some movements with their arms so we can observe how the breasts move then we'll get them to lie down and we'll place our hands on the patient's chest in a systematic manner pressing over the breast tissue note it's it's a small thing for me but personally i do not like the word feel to be used in an examination such as this a feel is a very emotive word and in many ways could be considered inappropriate there's a lot of personal preference here so for example if i'm examining someone's abdomen i'll frequently say i'm just going to feel around your tummy make sure there's any lumps and bumps that would be quite normal i think because we're trying to reassure the patient and tone and choice of words is vital that's particularly seen with the breast examination hence i would not offer to feel a patient's breasts but i would offer to examine their breasts and palpate over the breast tissue so i would offer to examine the patient's breasts and palpate so press over their breast tissue to see if we could find any problems such as lumps and bumps having gained adequate consent we need to organize for a chaperone it is exceptionally important to have a chaperone for an intimate examination and the examination should not proceed without ideally the chaperone should be a neutral and or trained party and they have two roles both to observe the examination to ensure no harm is coming to the patient due to inappropriate steps the chaperone also protects the clinician against false accusations from the patient frequently patients will ask if a relative is able to come into the room with them absolutely because this is an intimate examination and if a patient has found a breast lump for example they're likely to be exceptionally worried about this so having that support is crucially important but that patient is not impartial and we would also require a separate chaperone for that examination having gained consent and having our chaperone in the room we won't have the patient to disrobe whereupon we'd have them sat on the bed sitting upright here we want to assess for any obvious visual changes to the breast do there appear to be any abnormal changes to the nipples can we see any obvious induration so indents on the breast tissue is there any swelling or redness that might indicate a potential abscess can we see a strange coloration over the breast and changes the skin texture that might suggest something such as pordorange a condition where breast cancer has infiltrated into the lymphatics preventing drainage of the breast in the vast majority of cases where we initially observe the patient sat on the examination couch we won't see any abnormal features so we need to see if we can highlight any that will be done by getting the patient to put their hands on their hips and push down on their pelvis this will contract their pectoralis major muscles and may give rise to seeing dimples or lumps becoming evident which couldn't before because of in their placement on the chest wall then we get the patient to put their arms up behind their heads this elevates the breast and changes the lie once again over the chest wall with the patient in this position we may see once again new dimples potentially or lumps become visible that were not visible before to proceed with the examination we'll need to get the patient to lie flat so that we can assess the breast by doing palpation with the patient lying down again we're going to assess to see if we can see any changes in the breasts from a third position of difference then we need to initiate palpatine the breast given that we've previously seen that we have installed a cancer on the left breast here thus we'll treat that in the same way we would if a patient was complaining of problems with their left breast thus we'll start off on the right side again having made sure we've appropriately washed our hands we're going to start in the upper part of the chest region just below the shoulder this is the tail of spence and the breast tissue extends all the way up here and it's very important that this area is not forgotten as it can hide a cancer or potentially metastasis we're going to press down simply up and down up and down across the breast tissue and same again covering the whole breast systematically with the finger pulps for any lumps any changes in consistency of the skin or the fatty tissue underneath we're going to make sure we go all the way up to the edge of the sternum because again the breast will extend this far and then coming back across to the other side to ensure that all regions are adequately and appropriately uncovered there are some clinicians that prefer to do a circular approach starting in the center of the breast and coming out if we do have a lady with particularly large breasts then it would be appropriate to use both hands in order to palpate the breast tissue between our fingers we'd also need to press directly over the nipple to see if anything could be palpated from behind it after having assessed the non-problematic breast we're going to move on to the breast the patient has complained of an issue in again we'll start in the tail of spence moving down across the breast in a uniform manner making sure that we're covering all four quadrants of the breast in doing so i've already felt a fullness in this area as we'd expect from where we've placed our cancers and then again going over the far side of the breast and then i'm going to press down over the nipple again to make sure there's nothing hidden behind there we'd want to make sure that we focus then over the area where we have found an abnormality in order to be able to characterize it in terms of that characterization we'll use the space spit mnemonic in the same way that we pay particular attention to the tail of spence to make sure we're not missing any cancers of the breast we also need to make sure we pay close attention to the lymph nodes to ensure we haven't missed any spread once we've assessed the patient by palpating the breast we get the patient to sit up which will allow us to assess their lymph nodes now the lymph nodes of the head and neck can be seen in the video up here however when it comes to examining the lymph nodes of the axilla here in the armpit we need to get the patient to rest their arm onto ours and give us the full weight that is often quite a difficult challenge for the patient to do so we try as best to get them to relax the weight and then we're going to press on the inside on the top and on the outside of the armpit the axilla and then also against the chest wall this can potentially be very uncomfortable for the patient try it on yourself now press in your armpit and you're pressing up against the bone of your arm your humerus and then against the inside and the outside of your armpit and then finally rubbing so that you can feel the ribs with your fingers through the armpit that requires quite a degree of pressure not so it's painful but it is certainly an uncomfortable sensation we would then need to make sure we've done the same check on the opposite breast because we must make sure that both breasts have been assessed fully and there's absolutely no space for cutting corners here and then would check for any super supraclavicular lymph nodes by getting the patient to shrug their shoulders up to assess down above the clavicles again with the other arm we get the patient to rest their arm onto ours and we're going to press up inside the armpit then we're going to press up along the top of the armpit and we're going to press in with our fingers at the back of the armpit before pressing in against the chest wall any patient that is found to have lumps in the axilla or lumps on the breast regardless of clinical suspicion should be seen in the breast clinic there are a few fringe cases such as a young patient with what appears to be fibrocystic disease related their periods where we can cautiously watch and wait through one menstrual cycle other than that all patients with breast lumps ideally need to be assessed in the breast clinic i hope this has been a useful video for yourselves i've taken particular care about the words that i've used throughout breasts are not only a feature of women but are also found on men all men have breast tissue even if it is very small and as a result of that men as well will develop breast cancer i have personally seen one case of male breast cancer in my life and a high male breast cancer particularly highlights why it's vitally important to do the visual inspection of the nipple as it's normally there where a male patient will present say doctor i have a problem often when they've seen changes to the nipple or if there's a blood stain discharge because as a rule of thumb men don't check their breast tissue in the way that we would regularly advise women to do so so i hope this has been a useful video please don't forget to like and subscribe and please put a simple yes no comment down below as to whether or not you feel the be a benefit to us re-filming this video when we're able to with somebody wearing the trainer so that you can see the the full fluidity of the examination from the doctor and patient perspective okay with that take care and i'll see you in the next one you