Breast cancer physical examination: Difference between revisions

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[[Image:Peau d’ orange Appearance in Breast cancer.jpg|thumb|300px|'''Peau d’ orange''' appearance in breast cancer. Case courtesy of Rajendran MC. <nowiki>http://generalsurgeryclinics.blogspot.com/2013/06/peau-d-orange-appearance-in-carcinoma.html</nowiki>]]
[[Image:Peau d’ orange Appearance in Breast cancer.jpg|thumb|300px|'''Peau d’ orange''' appearance in breast cancer. Case courtesy of Rajendran MC. <nowiki>http://generalsurgeryclinics.blogspot.com/2013/06/peau-d-orange-appearance-in-carcinoma.html</nowiki>]]
{{Breast cancer}}
{{Breast cancer}}
{{CMG}} {{AE}}{{MGS}}{{Soroush}}
{{CMG}} {{AE}}{{Soroush}}{{MGS}}


==Overview==
==Overview==
[[Patient|Patients]] with breast cancer usually are generally well appearing. [[Physical examination]] of [[Patient|patients]] with breast cancer is usually remarkable for [[lump]] in the breast, peau d'orange, and inverted [[nipple]].
[[Patient|Patients]] with breast cancer usually are generally well appearing. [[Physical examination]] of [[Patient|patients]] with breast cancer is usually remarkable for [[lump]] in the breast, peau d'orange, and inverted [[nipple]].
==Physical Examination==
==Physical Examination==


===General Appearance===
===General Appearance===
*[[Patient|Patients]] with breast cancer are generally well appearing. [[Patient|Patients]] are generally oriented to time, place, and person.<ref name="PE">Breast Cancer. Ganfyd (2015) http://www.ganfyd.org/index.php?title=Breast_cancer#Presenting_Symptoms Accessed on january 16, 2016</ref><ref name="ss">Breast cancer. Canadian Cancer Society (2015) http://www.cancer.ca/en/cancer-information/cancer-type/breast/signs-and-symptoms/?region=on#ixzz3xScycfqv Accessed on January 16, 2016</ref>
*[[Patient|Patients]] with breast cancer are generally well appearing. [[Patient|Patients]] are generally oriented to time, place, and person.<ref name="PE">Breast Cancer. Ganfyd (2015) http://www.ganfyd.org/index.php?title=Breast_cancer#Presenting_Symptoms Accessed on january 16, 2016</ref><ref name="ss">Breast cancer. Canadian Cancer Society (2015) http://www.cancer.ca/en/cancer-information/cancer-type/breast/signs-and-symptoms/?region=on#ixzz3xScycfqv Accessed on January 16, 2016</ref>
*Nevertheless, in late stages patients appear ill, pale, and might present with decreased level of consciousness.
===Skin===
With respect to the disease stage and complications, the skin could be either normal, pale, or icteric.


===Vital Signs===
===Vital Signs===


*Vital signs are generally normal in early stages.
*Vital signs are generally normal in early stages.
*In advanced disease state, almost any abnormality is possible due to brain, bone, liver, and lung metastases.
*In the advanced disease state, almost any abnormality is possible due to brain, bone, liver, and lung metastases.


<br />
===HEENT===
===HEENT===


* HEENT examination of patients with [disease name] is usually normal.
* HEENT examination of patients with breast cancer is usually normal, particularly in the early stages.
*In metastatic breast cancer the following abnormalities might be present:
 
:*Icteric sclera due to liver metastasis
:*Ophthalmoscopic exam may be abnormal with findings of increased ICP due to brain metastasis.
:*Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae due to chemotherapy or widespread disease immunosuppression.
 
===Neck===
*Enlarged [[Supraclavicular lymph nodes|supraclavicular]] [[Lymph node|lymph nodes]]


OR
===Lungs===
* Pulmonary examination of patients with breast cancer is usually normal, particularly in early stages.
*In metastatic breast cancer the following abnormalities might be present suggesting [[Consolidation (medicine)|consolidation]] and [[pleural effusion]] due to metastatic disorder::


* Abnormalities of the head/hair may include ___
:*Asymmetric chest expansion OR decreased chest expansion
* Evidence of trauma
:*Hyporesonant lung auscultation
* Icteric sclera
:*Fine/coarse [[crackles]] upon auscultation of the lung bases either unilaterally or bilaterally
*[[Nystagmus]]
:*Rhonchi
* Extra-ocular movements may be abnormal
:*Vesicular breath sounds OR distant breath sounds
*Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
:*Normal/reduced [[tactile fremitus]]
*Ophthalmoscopic exam may be abnormal with findings of ___
* Hearing acuity may be reduced
*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
*[[Exudate]] from the ear canal
* Tenderness upon palpation of the ear pinnae/tragus (anterior to ear canal)
*Inflamed nares / congested nares
*[[Purulent]] exudate from the nares
* Facial tenderness
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae


===Neck===
===Heart===
* Cardiovascular examination of patients with breast cancer is usually normal/none contributory.


* Enlarged [[Supraclavicular lymph nodes|supraclavicular]] [[Lymph node|lymph nodes]]
===Breast===
===Breast===
*[[Lump]]
*[[Lump]]
:*May be attached to the skin or [[chest]] wall and cannot be moved.
:*May be attached to the skin or [[chest]] wall and cannot be moved.
:*The [[lump]] may feel hard, irregular in shape and very different from the rest of the [[breast]] [[Tissue (biology)|tissue]]
:*The [[lump]] may feel hard, irregular in shape and very different from the rest of the [[breast]] [[Tissue (biology)|tissue]]
:*The [[lump]] may be [[Tenderness (medicine)|tender]], but it is usually not [[Pain|painful]].
:*The [[lump]] maybe [[Tenderness (medicine)|tender]], but it is usually not [[Pain|painful]].
 
*Dimpling of the skin
*Dimpling of the skin
*[[Peau d'orange]]
*[[Peau d'orange]]
:*Thickening and dimpling of the skin
:*Thickening and dimpling of the skin
*Change in size of affected [[breast]]
*Change in size of affected [[breast]]
*Inverted [[nipple]]
*Inverted [[nipple]]
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*Crusting, [[Ulcer|ulcers]] or scaling on the [[nipple]] - in [[Paget's disease of the breast|Paget's disease of breast]]
*Crusting, [[Ulcer|ulcers]] or scaling on the [[nipple]] - in [[Paget's disease of the breast|Paget's disease of breast]]
*[[Discharge]] from [[nipple]] - mostly bloody
*[[Discharge]] from [[nipple]] - mostly bloody
===Respiratory===
[[Medical sign|Signs]] of [[metastasis]]
*[[Pleural effusion]]
*[[Consolidation (medicine)|Consolidation]]
===Abdomen===
[[Medical sign|Signs]] of [[metastasis]] to [[liver]]
*[[Jaundice]]
*[[Hepatomegaly]]
*[[Ascites]]
===Extremity===
Signs of metastasis
*[[Bone]] [[tenderness]]
*[[Pathology (disambiguation)|Pathological]] [[Bone fracture|fractures]]
===Neuromuscular===
Signs of [[metastasis]]
*[[Headache]]
*[[Seizure]]
*[[Personality change due to another medical condition|Personality change]]
*[[Papilledema|Papilloedema]]
===Neck===
* Neck examination of patients with [disease name] is usually normal.
OR
*[[Jugular venous distension]]
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Thyromegaly]] / thyroid nodules
*[[Hepatojugular reflux]]
===Lungs===
* Pulmonary examination of patients with [disease name] is usually normal.
OR
* Asymmetric chest expansion OR decreased chest expansion
*Lungs are hyporesonant OR hyperresonant
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Rhonchi
*Vesicular breath sounds OR distant breath sounds
*Expiratory wheezing OR inspiratory wheezing with normal OR delayed expiratory phase
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Bronchophony]] present/absent
*Normal/reduced [[tactile fremitus]]
===Heart===
* Cardiovascular examination of patients with [disease name] is usually normal.
OR
*Chest tenderness upon palpation
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*[[Heave]] / [[thrill]]
*[[Friction rub]]
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
*[[Heart sounds#Third heart sound S3|S3]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the stethoscope


===Abdomen===
===Abdomen===
* Abdominal examination of patients with [disease name] is usually normal.
* Abdominal examination of patients with breast cancer is usually normal/none contributory, particularly in the early stages.  
OR
*In metastatic breast cancer the following abnormalities might be present:
*[[Abdominal distension]]  
:*[[Abdominal distension]]
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant  
:*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Rebound tenderness]] (positive Blumberg sign)
:*A palpable abdominal mass in the right/left upper/lower abdominal quadrant due to peritoneal seeding
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
:*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Guarding may be present
:*Shifting dollness suggesting [[Ascites]]
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test


===Back===
===Back===
* Back examination of patients with [disease name] is usually normal.
*Back examination of patients with breast cancer is usually normal, particularly in the early stages.
OR
*In metastatic disease, vertebrae is one of the most common sites of metastasis, hence point tenderness over the vertebrae is quite common.  
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump


===Genitourinary===
===Genitourinary===
* Genitourinary examination of patients with [disease name] is usually normal.
* Genitourinary examination of patients with breast cancer is usually normal.
OR
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge


===Neuromuscular===
===Neuromuscular===
* Neuromuscular examination of patients with [disease name] is usually normal.
* Neuromuscular examination of patients with breast cancer is usually normal.
OR
*Patient is usually oriented to persons, place, and time
*Patient is usually oriented to persons, place, and time
* Altered mental status
* Altered mental status is possible in late-stage disease with brain metastasis, electrolyte abnormality or severe lung or liver disease due to metastasis.
* Glasgow coma scale is ___ / 15
:* Clonus may be present
* Clonus may be present
:* Reflex abnormalities either hyperreflexia/hyporeflexia/areflexia due to CNS metastasis or electrolyte disturbance
* Hyperreflexia / hyporeflexia / areflexia
:* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally in brain metastasis
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
:* Peripheral nephropathy is the common complication of breast cancer chemotherapy.  
* Muscle rigidity
::* Unilateral/bilateral sensory loss in the upper/lower extremity is probable finding in patients treated with
* Proximal/distal muscle weakness unilaterally/bilaterally
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
*Unilateral/bilateral upper/lower extremity weakness
*Unilateral/bilateral sensory loss in the upper/lower extremity
*Positive straight leg raise test
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*Positive/negative Trendelenburg sign
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*Normal finger-to-nose test / Dysmetria
*Absent/present dysdiadochokinesia (palm tapping test)


===Extremities===
===Extremities===
* Extremities examination of patients with [disease name] is usually normal.
* Extremities examination of patients with breast cancer is usually normal.
OR
* The followings are suggesting metastatic disorder:
*[[Clubbing]]
:*[[Cyanosis]] in lung metastasis
*[[Cyanosis]]  
:*Pitting[[edema]] of the lower extremities suggesting malnutrition and liver involvement
*Pitting/non-pitting [[edema]] of the upper/lower extremities
:*Muscle atrophy due to malnutrition is late stage metastatic cancer
*Muscle atrophy
:*[[Bone]] [[tenderness]]
*Fasciculations in the upper/lower extremity
:*[[Pathology (disambiguation)|Pathological]] [[Bone fracture|fractures]]


==References==
==References==

Latest revision as of 23:13, 1 October 2019

Peau d’ orange appearance in breast cancer. Case courtesy of Rajendran MC. http://generalsurgeryclinics.blogspot.com/2013/06/peau-d-orange-appearance-in-carcinoma.html

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2] Mirdula Sharma, MBBS [3]

Overview

Patients with breast cancer usually are generally well appearing. Physical examination of patients with breast cancer is usually remarkable for lump in the breast, peau d'orange, and inverted nipple.

Physical Examination

General Appearance

  • Patients with breast cancer are generally well appearing. Patients are generally oriented to time, place, and person.[1][2]
  • Nevertheless, in late stages patients appear ill, pale, and might present with decreased level of consciousness.

Skin

With respect to the disease stage and complications, the skin could be either normal, pale, or icteric.

Vital Signs

  • Vital signs are generally normal in early stages.
  • In the advanced disease state, almost any abnormality is possible due to brain, bone, liver, and lung metastases.

HEENT

  • HEENT examination of patients with breast cancer is usually normal, particularly in the early stages.
  • In metastatic breast cancer the following abnormalities might be present:
  • Icteric sclera due to liver metastasis
  • Ophthalmoscopic exam may be abnormal with findings of increased ICP due to brain metastasis.
  • Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae due to chemotherapy or widespread disease immunosuppression.

Neck

Lungs

  • Pulmonary examination of patients with breast cancer is usually normal, particularly in early stages.
  • In metastatic breast cancer the following abnormalities might be present suggesting consolidation and pleural effusion due to metastatic disorder::
  • Asymmetric chest expansion OR decreased chest expansion
  • Hyporesonant lung auscultation
  • Fine/coarse crackles upon auscultation of the lung bases either unilaterally or bilaterally
  • Rhonchi
  • Vesicular breath sounds OR distant breath sounds
  • Normal/reduced tactile fremitus

Heart

  • Cardiovascular examination of patients with breast cancer is usually normal/none contributory.

Breast

  • May be attached to the skin or chest wall and cannot be moved.
  • The lump may feel hard, irregular in shape and very different from the rest of the breast tissue
  • The lump maybe tender, but it is usually not painful.
  • Thickening and dimpling of the skin

Abdomen

  • Abdominal examination of patients with breast cancer is usually normal/none contributory, particularly in the early stages.
  • In metastatic breast cancer the following abnormalities might be present:

Back

  • Back examination of patients with breast cancer is usually normal, particularly in the early stages.
  • In metastatic disease, vertebrae is one of the most common sites of metastasis, hence point tenderness over the vertebrae is quite common.

Genitourinary

  • Genitourinary examination of patients with breast cancer is usually normal.

Neuromuscular

  • Neuromuscular examination of patients with breast cancer is usually normal.
  • Patient is usually oriented to persons, place, and time
  • Altered mental status is possible in late-stage disease with brain metastasis, electrolyte abnormality or severe lung or liver disease due to metastasis.
  • Clonus may be present
  • Reflex abnormalities either hyperreflexia/hyporeflexia/areflexia due to CNS metastasis or electrolyte disturbance
  • Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally in brain metastasis
  • Peripheral nephropathy is the common complication of breast cancer chemotherapy.
  • Unilateral/bilateral sensory loss in the upper/lower extremity is probable finding in patients treated with

Extremities

  • Extremities examination of patients with breast cancer is usually normal.
  • The followings are suggesting metastatic disorder:

References

  1. ↑ Breast Cancer. Ganfyd (2015) http://www.ganfyd.org/index.php?title=Breast_cancer#Presenting_Symptoms Accessed on january 16, 2016
  2. ↑ Breast cancer. Canadian Cancer Society (2015) http://www.cancer.ca/en/cancer-information/cancer-type/breast/signs-and-symptoms/?region=on#ixzz3xScycfqv Accessed on January 16, 2016

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