Study

1. Assessment of the Breast,
Axilla & Genitalia
Ashfaq Ahmad Sahil
Lecturer INS-KMU

2. Objectives
By the end of the unit, learners will be able to:
 Discuss the history questions pertaining to male and
female breast and Genitalia assessment.
 Perform a breast examination including axillary
nodes and interpret findings.
 Discuss components of a genital exam on a male
and female.
 Document findings.
 List the changes in breast, male & female
genitalia that are characteristics of aging process

3. Anatomy and Physiology of Breast

4. Breast quadrants

5. Clinical breast examination (CBE)
 Clinical breast examination (CBE) by a health
care professional every 3 years for women
between 20 and 39 years of age, and annually
after 40 years of age.
 Yearly mammography for women 40 years of
age and older.
 For women at increased risk, many clinicians
advise initiating screening mammography
between ages 30 and 40, then every 2 to 3
years until 50 years of age.

6. Assessing: Subjective Data
 History of Breast Disease and or Surgery
 Lumps or thickening
 Discharge/Rash
 Swelling/Trauma
 Pain
 Does patient perform self breast exam
monthly
 Axillary tenderness, lumps swelling, rash

7. Assessing: Objective Data
 Inspection- patient sitting, disrobed to waist
 Note symmetry, size and shape
 Skin normally smooth and even in color.
 Observe the axillary and supra clavicular
areas for any bulging, discoloration or edema
 Nipples- symmetrical? Flat? Inverted?
Discharge? Bleeding?

8. Screen for Retraction
Ask patient to:
 Lift arms slowly above head. Both breast
should move up symmetrically
 Push hands into hip.
 Arms at side
 Lean forward.

10. Inspect and Palpate Axillae
 While patient is sitting, lift and support the arm so
patient’s muscles are relaxed
 Use the right hand to palpate left axillae
 Reach fingers high into axillae
 Move fingers firmly down in four directions: –
Down the chest wall, along the anterior and
posterior borders of axillae and around the inner
aspect of the arm
 Move arm through ROM to have access to areas.

12. Breast Palpation
 Supine position with small pad/pillow under
side to be palpated
 Arm raised over head
 Use pads of fingers and make gentle rotary
movement on breast
 Use a pattern of concentric circles or
laterally, like spokes of wheel.
 Palpate all areas of breast, clockwise fashion
 Make sure to include tail of Spence.

13. Findings

16. Bimanual Breast Palpation
 For pendulous breasts
 Patient sitting, leaning forward
 Support inferior part of breast with one
hand.
 Use other hand to palpate breast tissue
against supporting hand.

17. Examination of Nipples
 Performed after breast palpation.
 Palpate nipple, noting any indurations
or mass.
 Use thumb and forefinger to apply
gentle pressure to note any discharge.

18. Characteristics of Breast Lumps
 Location- use breast as clock face to
describe distance from nipple in centimeters
(use diagram to locate).
 Size- in centimeters
 Shape: oval, round, lobulated or indistinct
 Consistency: soft, firm, or hard
 Movable: freely movable, fixed to chest wall
 Tenderness
 Nipple: displaced, retracted, dimpled?

19. Teaching (Self Breast Exam)BSE
 Assist patient to establish a schedule
 Regular monthly exams
 Majority of women never get breast
cancer, majority of lumps are benign
 Early detection is important.
 In non-invasive cancer, survival is close
to 100%

20. Self Breast Exam
 Teaching positions: –
1. Standing in front of mirror
2. 2. In the shower – soap and water assist
palpation
3. 3. Supine
 Keep teaching simple
 Demonstrate to patient and use return
demonstration

22. Patient Instructions for the
Breast Self-Examination (BSE)
1.Lie down with a pillow under your right shoulder.
Place your right arm behind your head.
2.Use the finger pads of the three middle fingers on
your left hand to feel for lumps in the right breast. The
finger pads are the top third of each finger.
3. Press firmly enough to know how your breast
feels. A firm ridge in the lower curve of each breast is
normal. If you’re not sure how hard to press, talk with
your health care provider, or try to copy the way the
doctor or nurse does it.

23. Cont…..
4.Press firmly on the breast in an up-and-down or
“strip” pattern. You can also use a circular or
wedge pattern, but be sure to use the same
pattern every time. Check the entire breast area,
and remember how your breast feels from month
to month.
5.Repeat the examination on your left breast,
using the finger pads of the right hand.
6.If you find any changes, see your doctor right
away.

24. Breast Examination Techniques

26. Standing
 1. Repeat the examination of both breasts
while standing, with one arm behind your
head. The upright position makes it easier to
check the upper outer part of the breasts
(toward your armpit). This is where about half
of breast cancers are found. You may want
to do the upright part of the BSE while you
are in the shower. Your soapy hands will
make it easy to check how your breasts feel
as they glide over the wet skin.

27. Cont…..
2.For added safety, you might want to check
your breasts by standing in front of a mirror right
after your BSE each month. See if there are any
changes in the way your breasts look, such as
dimpling of the skin, changes in the nipple,
redness, or swelling.
3.If you find any changes, see your doctor right
away.

28. The Male Breast
 Examination can be abbreviated but not
omitted.
 Inspect the chest wall noting skin surface and
any lumps or swelling.
 Palpate nipple area for lumps or
enlargement.
 Normal male breast has a flat disc of
undeveloped breast tissue beneath the
nipple. Should be even with no nodules

29. Gynecomastia

30. Documentation: Female
 S- Denies breast pain, lump, discharge, rash,
swelling, trauma. Denies past history of breast
disease or surgery. States performs monthly
breast exams.
 O- Inspection: Breasts symmetric. Skin smooth
with even color. No dimpling or retraction
elicited. No nipple discharge. No lesions.
 Palpation: Breast contour and consistency firm
and homogeneous. No masses or tenderness.
No lymphadenopathy.

31. Cont….
 A- Healthy breasts bilaterally with no
S/S of abnormalities
 P- Reinforce BSE (patient performs
BSE monthly), follow up with MD for
referral for mammogram

32. Male Genitalia

33. Health History
 “What is your relationship status? Tell me
about your sexual preference.”
 “How is sexual function for you?”
 “Are you satisfied with your sexual life?”
 “What about your ability to perform sexually?”
 To assess libido, or desire: “Have you
maintained an interest in sex?”
 For the arousal phase: "Can you achieve and
maintain an erection?”

34. Cont…..
 Premature ejaculation?
 Inquire about sores or growths on the penis
and any pain or swelling in the scrotum
 STDs may involve other parts of the body.
Ask about practices of oral and anal sex and
any related sore throat, oral itching or pain,
diarrhea, or rectal bleeding

35. Health promotion and counselling
 Prevention of STDs and HIV Infection. Focus
on patient education about STDs and HIV, early
detection of infection during history taking and
physical examination, and identification and
treatment of infected partners.
 Identify the patient’s sexual orientation, the
number of sexual partners in
 the past month, and any history of STDs.

36. Cont…..
 Testicular Self-examination. Encourage
men, especially those between 15 and 35
years of age, to perform monthly testicular
self-examinations

37. Examination techniques

38. Cont….

39. Cont….

40. Patient instructions for the
Testicular Self-Examination
This examination is best performed after a
warm bath or shower. The heat relaxes the
scrotum and makes it easier to find anything
unusual.
 Standing in front of a mirror, check for any
swelling on the skin of the scrotum.
 Examine each testicle with both hands. Cup
the index and middle fingers under the
testicle and place the thumbs on top.

41. Cont…
 Roll the testicle gently between the thumbs and
fingers. One testicle may be larger than the other . . .
that’s normal, but be concerned about any lump or
area of pain.
 Find the epididymis. This is a soft, tube-like structure
at the back of the testicle that collects and carries
sperm, not an abnormal lump.
 If you find any lump, don’t wait. See your doctor.
The lump may just be an infection, but if it is
cancer, it will spread unless stopped by treatment.

43. Female Genitalia

44. Health History
Menstrual History
 When her menstrual periods began (age at
menarche)
 When did her last period start, and the one
before that?
 What is the interval between periods, from
the first day of one to the first day of the next?
 Are menses regular or irregular?
 How long do they last? How heavy is the flow?

45. Cont…..
 Dysmenorrhea, or painful menses, is common.
 Amenorrhea is the absence of periods.
 Failure to begin periods is called primary
amenorrhea, while cessation of established
periods is termed secondary amenorrhea.
 Menopause, the absence of menses for 12
consecutive months, usually occurs between 48
and 55 years.

46. Cont……
 Amenorrhea from Pregnancy
 Common early symptoms are:
 Tenderness, tingling, or increased size of
breasts
 Urinary frequency; nausea and vomiting
 Easy fatigability; and feelings that the baby
is moving.

47. Cont….
 To assess sexual function, start with general
nonjudgmental questions like “How is sex for
you?” or “Are you having any problems with sex?”
 These questions help you assess each phase of
the sexual response: desire, arousal, and orgasm.
 Ask also about dyspareunia, or discomfort or pain
during intercourse.
 Sexually transmitted diseases (STDs),

48. Tips for the Successful Pelvic
Examination
 Patient
 Avoids intercourse, douching, or use of vaginal
suppositories for 24 to 48 hours before
examination.
 Empties bladder before examination
 Lies supine, with head and shoulders elevated,
arms at sides or folded across chest to enhance
eye contact and reduce tightening of abdominal
muscles.

49. Cont….
 The Examiner
 Obtains permission
 Explains each step of the examination in
advance
 Drapes patient from mid-abdomen to knees;
depresses drape between knees to provide eye
contact with patient
 Avoids unexpected or sudden movements

50. Cont…..
 Chooses a speculum that is the correct size
 Warms speculum with tap water
 Wears gloves
 Monitors comfort of the examination by
watching the patient’s face
 Uses excellent but gentle technique,
especially when inserting the speculum
 Male examiners should be accompanied by
female assistants.

51. Assessment (External Genitalia)

52. Cont…..

56. Cont….
 Any discharge or bleeding
 Any ulcers, nodules, or masses
 Obtain specimens for cytology (Pap smears)
with
 Inspect the vaginal mucosa as you withdraw
the speculum.

57. Cont……
 Palpate, by means of a bimanual
examination,
 The cervix and fornices
 The uterus
 Right and left adnexa (ovaries)
 Observe for any hernias

59. References
 Bates' Pocket Guide to Phys. Examination
and Hist. Taking 6th ed. - L. Bickey, et al.,
(Lippincott, 2009) BBS

60. Summary