BREAST, HYDRATION AND BONY TENDERNESS
A.Breast: It is a part of routine clinical examination, especially during examination of
the chest and respiratory system. Male doctor must call a female attendant, and will
examine the female breast giving dignity to the patient’s self-respect and sensitivity.
Ask her to undress up to the waist and sit upright on a stool.
Ask her to hang the arms relaxed by the sides: Observe the size, symmetry, contour
and colour of the breast; look for peau d’orange (orange peel skin) colour and
texture of the skin commonly found in breast carcinoma (Fig. 2.105). Look for
any asymmetry or inversion (especially of recent origin) of the nipple, or retraction
of the areola; nipple should be examined by index finger and thumb, while the
colour and consistency of the discharge from the nipple is noted, if there is any.
Dimpling on overlying skin should be noted.
Ask her to raise her arms above her head: It may reveal very minor contour abnormality.
Ask her to lie supine and to rest one arm above her head: Now examine all the four
quadrants of relaxed and widespread breast tissue with holding your hand flat
over the breast tissue, especially using the pads of your middle three fingers. In a
larger breast, other hand of yours may support the breast tissue during
examination. Compare the texture of one breast with the other one. Palpate all
quadrants very meticulously and systematically in the search of a nodule (note
the size, shape, consistency, mobility, tenderness, or any tethering or ulceration
present on the overlying skin) or tumour; use rotatory movements of your hands
with compression of the breast tissue on the chest wall. Palpate the axillary tail
present in the upper outer quadrant, and the areola.
Normal breast tissue is variable in feel ranging from smooth to granular.
Now ask her to press her hands against her hips: Again examine the nodule or lump
for mobility; it will be less mobile, if attached to pectoral muscles. Assess the
fixity of skin overlying the lump.
According to some clinical surgeons, inspection of the breast is done in a standing
patient adopting the following position by: (a) hands resting on thighs, (b) hands
pressed on to hips, (c) both the arms rest above head, and (d) leaning forward
while the breasts become pendulous. Palpation of one-sided breast is better done
on a supine patient with her head on a pillow and her hand placed under her
head on the side of examination.
Male breast is also examined for gynaecomastia or for any tumour (rare).
Lipomastia (no breast tissue, only fat deposition due to obesity) is
better palpated by flat of the hand while gynaecomastia is best appreciated by
finger
Hydration: To assess the hydration status, look for the following sites and facts.
Signs of dehydration are dry tongue, shrunken eyes, loss of skin turgor, presence of
postural hypotension, low intraocular tension (i.e., soft eyeballs), low jugular venous
pressure in supine position of the patient, and oliguria. Facies in dehydration (facies
Hippocraticus) has been described in the section of ‘Facies’.
Some pathological conditions may cause overhydration, which need early diagnosis
like congestive cardiac failure (CCF), nephrotic syndrome, chronic renal failure,
cirrhosis of liver, uncontrolled diabetes mellitus and as a side effect of NSAID (nonsteroidal
anti-inflammatory drug) use.
C. Bony tenderness: It may be present in primary malignancy of bone, metastases in
bone, infection (osteomyelitis), trauma, osteomalacia, multiple myeloma, leukaemias
(acute leukaemias and chronic myeloid leukaemia), osteoporosis, or in overuse.
Bony tenderness may be tested over sternum (the so-called sternal tenderness is elicited
by pressing the ball of the thumb over the upper part of the body of sternum for
2–3 seconds, when the patient winces with pain if it is present), pelvic bones, ribs,
upper part of shin bone, spine (i.e. vertebrae), and frontal bone.