Key Components of a Comprehensive Review of Systems (ROS) for the Female Breast
A comprehensive Review of Systems (ROS) for the female breast should follow a standardized, stepwise approach that includes clinical history, visual inspection, and systematic palpation to ensure thorough evaluation and early detection of abnormalities. 1
Clinical History Components
- Previous breast examinations and imaging results (mammograms, ultrasounds, MRIs)
- Risk factors for breast cancer:
- Family history of breast or ovarian cancer
- Personal history of breast biopsies
- Prior radiation to the chest
- Pregnancy status
- Breast symptoms:
- Presence of masses or lumps
- Pain or tenderness (cyclical vs. non-cyclical)
- Nipple discharge (color, consistency, spontaneous vs. expressed)
- Skin changes (dimpling, redness, thickening)
- Nipple changes (inversion, retraction, Paget's disease)
- Previous breast surgeries or procedures
- Current medications (especially hormonal therapies)
Visual Inspection Components
Perform in multiple positions:
- With patient sitting, arms at sides
- With patient sitting, arms raised above head
- With patient sitting, hands pressed on hips (to contract pectoral muscles)
Assess for:
- Breast symmetry (size, shape, contour)
- Skin changes:
- Color (erythema, hyperpigmentation)
- Texture (edema, thickening, "orange peel" appearance)
- Dimpling or retraction
- Visible masses or bulging
- Nipple-areolar complex:
- Position and symmetry
- Inversion or retraction
- Discharge (spontaneous)
- Skin changes or lesions
Palpation Components
Technique
- Use the vertical strip pattern covering the entire breast from:
- Clavicle to inframammary fold
- Sternal midline to midaxillary line 2
- Use the pads of the three middle fingers (index, middle, ring)
- Apply three levels of pressure in sequence:
- Light (subcutaneous tissue)
- Medium (middle level)
- Deep (to thoracic wall) 2
Areas to Examine
- Breast tissue in all four quadrants (with special attention to upper outer quadrant)
- Nipple-areolar complex (palpate, not squeeze)
- Axillary lymph nodes
- Supraclavicular lymph nodes
- Infraclavicular lymph nodes
Patient Positioning
- Supine position with arm raised on the side being examined
- Sitting position for lymph node examination
Documentation Components
Document findings with specific details:
- Location of any abnormalities (using clock-face notation)
- Size of any masses (in mm)
- Characteristics of masses:
- Consistency (soft, firm, hard)
- Mobility (fixed vs. mobile)
- Borders (well-defined vs. ill-defined)
- Tenderness
- Skin changes (if present)
- Nipple discharge (if present):
- Color
- Consistency
- Whether from single or multiple ducts
- Whether spontaneous or expressed
Interpretation and Reporting
The examination should be interpreted as either:
- Normal/negative: No abnormalities in visual inspection or palpation
- Abnormal: Asymmetric finding in visual inspection or palpation that justifies further evaluation 2
If abnormal, the report should include:
- Description of visual and palpable findings
- Changes in appearance of skin or nipples
- Presence of nipple discharge
- Presence of breast masses or palpable asymmetries
- Presence of palpable lymph nodes 1
Common Pitfalls to Avoid
- Incomplete examination: Failing to cover the entire breast tissue area
- Inadequate pressure: Not using all three levels of pressure during palpation
- Overlooking the axilla: Neglecting to examine lymph nodes
- Ignoring subtle changes: Missing early signs of abnormalities
- Improper documentation: Failing to accurately record findings 2
Remember that the upper outer quadrant and the area under the areola/nipple are the two most common sites for breast cancer to appear, requiring particular attention during examination 2.
By following this comprehensive approach to the breast ROS, clinicians can ensure thorough evaluation and early detection of abnormalities that may require further investigation.