What is the recommended input order for a breast physical examination (PE) in an adult patient with no known breast abnormalities or concerns?

Clinical Breast Examination Order for Unremarkable Presentation

For an adult patient with no breast abnormalities or concerns, perform the clinical breast examination in this specific sequence: clinical history, visual inspection with patient sitting, lymph node palpation with patient sitting, then systematic breast palpation with patient supine. 1

Step 1: Clinical History

• Document screening practices including previous breast self-examinations, clinical breast examinations, and mammograms 1
• Assess risk factors including age, personal history of benign breast disease, and family history 1
• Ask about any breast changes including skin/nipple changes, lumps, pain, itching, or spontaneous nipple discharge, even if the patient reports no concerns 1

Step 2: Visual Inspection (Patient Sitting)

• Position the patient sitting upright with hands pushing tightly on hips to contract the pectoralis major muscles and enhance identification of asymmetries 1
• View breasts from all sides, assessing symmetry in breast shape or contour, skin changes, and nipple changes 1
• Use the BREAST acronym to systematically check for signs: Breast mass, Retraction, Edema, Axillary mass, Scaly nipple, and Tender breast 1

Step 3: Lymph Node Palpation (Patient Sitting)

• Begin with the patient still sitting to palpate axillary, supraclavicular, and infraclavicular lymph nodes 1
• This position allows optimal access to lymph node regions before transitioning to supine positioning 1

Step 4: Systematic Breast Palpation (Patient Supine)

• Position the patient lying down with ipsilateral hand overhead to flatten breast tissue on the chest wall 1
• Use the finger pads of the middle three fingers to palpate one breast at a time with overlapping dime-sized circular motions 2, 1
• Cover the entire pentagon-shaped area of breast tissue using specific anatomic landmarks: sternum to inframammary ridge, to midaxillary line, to clavicle, and back to sternum 2, 1
• Use a vertical strip pattern moving from top to bottom to ensure thorough coverage of all breast tissue 2, 1
• Apply three levels of pressure sequentially at each area: light (tissue closest to skin), medium (a little deeper), and deep (closest to chest wall) 2, 1
• Pay special attention to the upper outer quadrant and the area under the areola/nipple, as these are the most common sites for cancer to arise 1

Critical Time Consideration

• A thorough examination of an average-sized breast takes several minutes 2, 1
• Explain to the patient beforehand that a careful examination requires adequate time to avoid misunderstandings or discomfort 2, 1

Common Pitfalls to Avoid

• Never rush the examination, as thoroughness is essential for detection 1
• Never use inadequate pressure levels during palpation, which can miss deeper lesions 1
• Never squeeze the nipple instead of using gentle palpation 1
• Never fail to cover the complete pentagon-shaped perimeter of breast tissue 1
• Never skip informing the patient about the examination process beforehand 1