Breast physical exam documentation

What follows is directed to the more novice examiner: If you clearly identify a discrete mass, consider it to be malignant until proven otherwise. Laboratory results: Liver function tests normal. Advertising revenue supports our not-for-profit mission. Guidelines The National Comprehensive Cancer Network screening guidelines suggest that women between 25 and 40 years old who are asymptomatic and have no special risk factors for breast cancer undergo a clinical breast exam every 1 to 3 years. Clinical Anatomy The adult breast is roughly conical, the base of which overlies the pectoralis muscles in the upper portion of the chest [4].

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Clinical Breast Exam

In contrast, mammography performed with or without CBE , has a strong body of evidence to support its routine use as a screening tool for early detection of malignancy. National Cancer Institute. A suspicious lump —the type your physician is checking for— is generally about the size of a pea before anyone can feel it in the breast tissue. A breast exam in a male is often somewhat simpler due to a smaller volume of tissue to assess unless the patient is extremely obese or gynecomastia is present. A more complex example would be if the patient had a mass in the mastectomy scar. SKIN: Inspection of the skin and subcutaneous tissues appeared to be normal. Clinical assessment of the breast Objectives Case studies History taking The examination of the breasts Case studies 3.

Screening and Prevention | Breast Care Program | Columbia University Department of Surgery

Clinical assessment of the breast. Systematically examine all areas of the breast with your hand laid flat on the breast. For this reason I have found the physical examination component of any EMR software to be the most cumbersome and difficult to implement. PMH past medical history : SM is moderately overweight, but otherwise in good health. A firm ridge along the bottom of each breast is normal, for instance. A breast self-exam for breast awareness is a safe way to become familiar with the normal look and feel of your breasts.
This allows the examiner to assess the breasts in many positions and observe overall size, shape, symmetry, nipple size, shape, texture, and color. Introduce yourself to the patient and clarify their identity. Columbia University Irving Medical Center. She experienced menarche at age 10, had her first and only child at age 36, and experienced menopause at age A clinical breast exam is performed by a healthcare professional who is trained to recognize many different types of abnormalities and warning signs. If the patient is comfortable, she should undress down to her waist and put on a gown.
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