Breast cancer physical examination

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: Mirdula Sharma, MBBS [2] Soroush Seifirad, M.D.[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.

Vital Signs

• 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.

HEENT

• HEENT examination of patients with breast cancer is usually normal, particularly in 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
• Hearing acuity may be reduced due to chemotherapy
• Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae due to chemotherapy or widespread disease immunosuppression.

Neck

• Enlarged supraclavicular lymph nodes

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:

• Asymmetric chest expansion OR decreased chest expansion
• Lungs are hyporesonant
• 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

Breast

• Lump

• 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 may be tender, but it is usually not painful.

• Dimpling of the skin
• Peau d'orange

• Thickening and dimpling of the skin

• Change in size of affected breast
• Inverted nipple
• Redness, swelling and increased warmth - in inflammatory breast cancer
• Crusting, ulcers or scaling on the nipple - in Paget's disease of breast
• Discharge from nipple - mostly bloody

Respiratory

Signs of metastasis

• Pleural effusion
• Consolidation

Abdomen

Signs of metastasis to liver

• Jaundice
• Hepatomegaly
• Ascites

Extremity

Signs of metastasis

• Bone tenderness
• Pathological fractures

Neuromuscular

Signs of metastasis

• Headache
• Seizure
• Personality change
• Papilloedema

Heart

• Cardiovascular examination of patients with breast cancer 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
• S1
• S2
• S3
• S4
• 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

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

OR

• Abdominal distension
• 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
• Guarding may be present
• Hepatomegaly / splenomegaly / hepatosplenomegaly
• Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test

Back

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

OR

• Point tenderness over __ vertebrae (e.g. L3-L4)
• Sacral edema
• Costovertebral angle tenderness bilaterally/unilaterally
• Buffalo hump

Genitourinary

• 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 examination of patients with breast cancer is usually normal.

OR

• Patient is usually oriented to persons, place, and time
• Altered mental status
• Glasgow coma scale is ___ / 15
• Clonus may be present
• Hyperreflexia / hyporeflexia / areflexia
• Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
• Muscle rigidity
• 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 examination of patients with breast cancer is usually normal.

OR

• Clubbing
• Cyanosis
• Pitting/non-pitting edema of the upper/lower extremities
• Muscle atrophy
• Fasciculations in the upper/lower extremity