APGO Clinical Skills Curriculum. The Breast Exam

Transcription

1 APGO Clinical Skills Curriculum The Breast Exam Association of Professors of Gynecology and Obstetrics (APGO) Undergraduate Medical Education Committee 2008

2 The Breast Exam Table of Contents Intended Learning Outcomes 3 Description 4 Best Practices 6 Checklist 7 Performance Assessment 8 Practical Tips 9 Resources 10 2

3 Intended Learning Objectives The American Cancer Society recommends that women in their 20s and 30s should have a clinical breast exam (CBE) as part of a periodic health exam by a health professional, preferably every three (3) years. After age 40, women should have a breast exam by a health professional every year. CBE is a complement to mammograms and an opportunity for women and their doctor or nurse to discuss changes in their breasts, early detection testing, and factors in the woman s history that might make her more likely to have breast cancer. The purpose of teaching the medical student how to perform the clinical breast exam is to: 1. Train them to detect a lump or change in the appearance of the breast that may indicate breast cancer 2. Teach them to evaluate other breast conditions that may require medical attention, such as mastitis 3. Teach them the appropriate communication skills when performing a sensitive exam, such as the breast examination, on patients 3

4 Description General Approach/Interpersonal Skills The student should introduce him or herself to the patient, confirm the patient s name and how she wants to be addressed. The student should wash hands with soap and warm water and dry with a towel or alcohol based antiseptic. The student should inform the patient that he/she is performing a breast exam. This is a good time to ask the patient if she has noticed any lumps or other problems with her breasts. The student should be organized and have the patient properly draped, i.e. cover areas not being examined. The student should close the examination in an appropriate manner. Inspection Asking the patient to lower the gown, the student should visually inspect the breasts from front and sides. The student should look for size, symmetry (some variation is normal), shape, contour (flattening, masses, and dimpling), skin (color, edema, rashes, thickening, and venous pattern), and scars (previous surgery, injuries). The student should do the inspection with the patient performing arm maneuvers: overhead (picture #1), waist (picture #2), and leaning forward (picture #3). The student is looking for any retraction when the patient is leaning forward, or contracting the pectoral muscles. # 1 #2 #3 Palpation 1. Lymph nodes Cervical nodes: These nodes are found along the sides of the neck. 4

5 Axillary nodes: Patient in seated position using appropriate draping technique. With patient s arm at side and examiner lifting arm away from side to access nodes (picture #4). Supraclavicular nodes: These nodes are found along a line immediately above the clavicle. This is done by the student stepping around behind the patient. #4 2. Bimanual palpation while patient sitting: The student should perform bimanual palpation with the patient in a seated position, using appropriate draping technique. The student should use the right hand above the left hand below to palpate the right breast. Student should use the pads of the fingertips to compress the breast tissue between fingertips. Using this technique, the student can check for consistency, nodules, masses, and tenderness, which might not be felt in supine breast exam. Repeat for left side by standing on patients left side and reversing hands (left on top, right on bottom). 3. Complete breasts palpation while patient is supine: The student should pull out the footrest, and ask the patient to put her arm overhead during supine palpation. The arm overhead helps to stretch the breast tissue against the chest wall. The student then performs complete palpation of the breasts. Use the flat part of the fingers (and a rotary motion) against the chest wall using a radial or spiral pattern without missing areas, compressing the breast tissue against the chest wall in all quadrants of the breast (picture #5). Student should be noting tissue consistency, elasticity, nodules, indurations, masses, and tenderness. 5

6 #5 The student also performs palpation of breast tissue, which continues up the chest wall to the clavicle (collar bone) and towards the axilla (armpit). The student inspects and palpates the nipples (picture #6), looking for size, shape, inversion, rashes, ulceration, discharge, scaling, crusting, elasticity, retraction, areolar edema and masses. The student then should gently grasp and compress the nipple and areolar tissue between thumb and index finger, noting the color consistency and quantity of any discharge (picture #7). #6 #7 Best Practices A comprehensive literature review 1 has shown that students learning breast examination from standardized patients perform better than students taught by faculty (as assessed by a clinical examination). Students learning breast examination by using silicone models have higher sensitivity for detecting breast lumps (as assessed by ability to detect lumps in silicone breast models). Students who learn communication skills from patients with cancer have better skills and attitudes than students learning from non cancer patients. Therefore we recommend that standardized patients be used to teach the clinical breast examination to medical students, in combination with practicing on silicone models. 1 Gaffan J, Dacre J, Jones A. Educating undergraduate medical students about oncology: A literature review. J Clin Oncol 2006;24(12):

7 Checklist General Approach/ Interpersonal/ Communication Skills Properly introduced himself/herself to patient Established and maintained rapport with patient Washed his/her hands or prepped with antiseptic Used appropriate draping techniques Performed the exam in an organized fashion Made the patient feel comfortable Used good non verbal skills Closed the exam in an appropriate manner Inspection With patient sitting, inspected both breasts from front and sides Asked patient to put arms overhead Asked patient to put arms on her waist and press elbows forward Asked patient to lean forward with arms out in front Palpation With patient sitting, palpated the cervical, supraclavicular and axillary lymph node With patient sitting, performed bimanual palpation of the breast With patient supine, performed the following: Asked patient to put arms overhead Performed complete palpation of the breast with the flat part of the fingers Performed palpation of the axillary tail Gently palpated and expressed nipples Well Done Needs Improvement Not Done Cannot Recall 7

8 Global Assessment Student s overall performance was: Excellent Very Good Good Fair Poor Performance Assessment Breast examination skills are best assessed through direct observation or a standardized patient exercise. The checklist, above, can be used for performance assessment. Below is a case scenario, which can be used for a standardized patient station, followed by an example of a post encounter note if desired (modeled after USMLE Clinical Skills Exam). Instructions for the Breast Mass Station This station is 30 minutes in length. The first 15 minutes are spent interviewing the patient and performing an appropriate physical exam. The last 15 minutes are spent writing a post encounter note, which includes pertinent history, physical exam findings, differential diagnosis, and diagnostic workup plan. Please note that students are expected to obtain a focused history, family history, social history and medications, and are expected to perform a complete breast examination. Make sure students discuss their initial diagnostic impression and workup plan with the patient. Once students leave the examination room, they may not re enter. They are expected to complete their note and give it to the staff when finished. Case Scenario This is a 15 minute station; the staff member will knock on the door when five (5) minutes remain and at the end of the session. Ms. Smith is a 52 year old female, who came to the clinic today because she noticed a breast lump while taking a shower last week. Vital signs: BP 135/80 P 70/min R 14/min Temp 99.5 F (37.5 C) Student tasks are to: 1. Obtain a focused history 2. Perform a relevant physical examination 8

9 3. Discuss initial diagnostic impression and workup plan with the patient 4. After leaving the room, complete patient note on the form provided Post Encounter Note History: Include significant positives and negatives from history of the present illness, past medical history, review of systems, social history, and family history. HPI: Location, how was it noted, how long present, has it changed in size, does it change with menstrual cycle, any nipple discharge? PMHx: Breast disease or cancer, age at menarche, age at first pregnancy, menopause status? PSHX: Breast biopsies? Social: Smoking, alcohol use, exercise? Family Hx: Breast or ovarian cancer Medications: OCPs or hormones Physical Examination: Indicate only pertinent positive or negative findings related to the patient s chief complaint. Patient s weight Breast exam findings as per checklist Differential Diagnoses: With 1 being the most likely, list up to 5 potential or possible diagnoses for this patient s presentation (in many cases, fewer than 5 diagnoses are likely): 1. No mass detected 2. Fibrocystic changes 3. Carcinoma Diagnostic Workup: List immediate plans (up to 5) for further diagnostic workup: 1. Mammogram 2. Possible ultrasound 3. If mass, biopsy 4. If no mass, close follow up 5. Practical Tips We suggest that the breast examination be introduced to the students during the first two years of medical school in the form of didactics, practice on models and a standardized patient exercise (SP). The SP may be repeated during the clinical years. The performance assessment may occur as part of an objective structured clinical examination at the end of the obstetrics and gynecology clerkship or at the end of the third year. 9

10 Resources Textbook Batesʹ Guide to Physical Examination & History. Seventh Edition. By Lynn S. Bickley, Robert A. Hoekelman, Barbara Bates. Chapter 10; The Breasts and Axillae, pages Models technologies.net/shopsite/product252.html 3. R44CA rouilly.co.uk/products.php?catid=53 10