Outline the steps of a comprehensive breast exam, including patient positioning and what you assess.

• A. Palpate first, then inspect; check only one quadrant.
• B. Position seated or supine; expose for inspection; inspect symmetry, skin changes, retraction; palpate in a systematic pattern (quadrants and tail of spence); palpate axillary and supraclavicular nodes; compare sides; document findings.
• C. Do not document findings.
• D. Always perform MRI.

Answer: (B)

A comprehensive breast exam begins with proper positioning to allow full visualization and access: the patient can be seated for inspection and then moved to a supine position for thorough palpation, ensuring the chest and axillary regions are exposed. Start with inspection—look for symmetry between the breasts, skin changes such as redness, edema or peau d’orange, nipple inversion or recent discharge, and any dimpling or retraction. Compare sides and notice any scars, implants, or prior surgeries that might affect interpretation.

Proceed to palpation with a systematic plan that covers all breast tissue, including the quadrants and the tail of Spence. Use the pads of the fingers and a consistent technique (such as circular, wedge, or vertical strip) to assess for masses, noting their size, shape, consistency, mobility, edge, tenderness, and whether they feel fixed to skin or underlying tissue. Evaluate tissue density and identify any areas of focal thickening. Don’t forget to examine the axillary and supraclavicular regions for enlarged or fixed lymph nodes, describing their size, consistency, tenderness, and whether they’re mobile or fixed to surrounding structures.

Throughout the exam, compare findings between the left and right sides and document them clearly, including precise location (often described with a clock-face reference and distance from the nipple), size, and any associated skin or nipple changes. Documentation should guide further steps if anything suspicious is found, such as imaging or referral. Note that MRI is not routinely part of the physical exam and is reserved for specific indications.