Breast examination

With the patient sitting facing the examiner, the breasts are inspected, first with the patient’s arms at her sides and then with her arms raised above her head (Fig. 1.1). The shape, contour and size of the breasts, their height on the chest wall, and the position of the nipples are compared, any nipple retraction being noted. The supraclavicular regions and axillae are next palpated. The latter can only be palpated satisfactorily if the pectoral muscles are relaxed. This relaxation can be obtained if the physician supports the patient’s arms while palpating the axillae. Palpation is then performed with the patient lying supine, her shoulders elevated on a small pillow. Palpation should be gentle and orderly, using the flat of the fingers of one hand. Each portion of the breast should be palpated systematically, beginning at the upper, inner quadrant, followed by palpation of each portion sequentially until the upper, outer quadrant is finally examined.

Fig. 1.1 Breast self-examination. (A) Inspection of the breasts – the patient’s arms at her side. (B) Inspection of the breasts – the patient’s arms raised above her head. During the inspection, the contour of the breasts, the size and shape of the areolae and the condition of the nipples are examined. An indentation or a bulge in the contour may indicate a lesion. (C) Placing hand on hip tenses the pectoralis major, accentuating any tethering from an infiltrating neoplasm. (D) Axillary palpation. (E) Systematic examination of four quadrants of the breast. (F) Palpation of the upper outer quadrant of the breast.

The breast self-examination that many doctors recommend to women is similar to the breast examination made by the doctor, except that the woman usually does not palpate the axillary area. Figure 1.1 demonstrates how a woman should examine her breasts. The technique can easily be taught to her by her doctor.

Abdominal examination

The examination is conducted with the patient lying comfortably on her back, having emptied her bladder immediately beforehand. Inspection of the abdomen will show its contour, and the presence of striae and scars or of dilated veins. If the patient raises her head and coughs, hernias and divarication of the recti abdominis muscles will be evident. Palpation of the viscera is performed systematically, the liver, the gallbladder, the spleen and the kidneys being palpated in turn. The caecum and colon are next palpated, the hand pressing down gently as the patient breathes out. Percussion may be required if the presence of free fluid is suspected.

Pelvic examination

The pelvic examination should follow the abdominal examination and should never be omitted unless the patient is a virgin. The external genitalia are first inspected under a good light with the patient in the dorsal position, the hips flexed and abducted, and knees flexed. If she or the doctor prefers, she may lie in the left lateral position. Some women are more comfortable and feel less exposed in the latter position. The patient must have voided just before the examination (unless she is complaining of stress incontinence), and should preferably have defacated that morning. If urinary infection is suspected, a midstream specimen of urine may be obtained at this time.

The patient is asked to strain down, to enable detection of any evidence of prolapse, after which a bivalve speculum is inserted and the cervix visualized. For the woman’s comfort the speculum should be warmed and the doctor’s approach sensitive and communicative. If the physician intends to take a cervical smear to examine the exfoliated cells, no lubricant apart from water should be used on the speculum. The vagina and cervix are inspected by opening the bivalve speculum (Fig. 1.2). If the patient has a prolapse, the degree of the vaginal wall or uterine descent can best be assessed if a Sims speculum is used, with the patient in the left lateral position (Fig. 1.3).

Fig. 1.2 Introducing the bivalve speculum. Care should be taken to avoid applying painful pressure on the urethra by inserting the speculum initially obliquely.

Fig. 1.3 The patient in the left lateral position; a Sims speculum has been inserted into the vagina.