Indirect lighting can help to identify irregularities
Hands on hips, then stretch arms above head or tense pectoralis to accentuate asymmetries or dimpling
Lymphoedema of arm
Palpate
Axilla best examined while sitting
Both supraclavicular and infraclavicular spaces (from behind)
Supine with head supported and arms above head
Palpate both breasts systematically by quadrants, pushing breast tissue against chest wall
Masses - size relative to breast, shape, consistency, location, fixation
Specific findings
Nipple discharge
Gently squeeze the nipple to express
Note whether emerging from single or multiple ducts, and whether blood is present
Mastalgia
Differentiate chest wall tenderness from breast tenderness - use your hand from below to push away breast tissue, or put the patient on their side, allowing the breast to fall away medially
Peau d'orange
Hallmark of inflammatory carcinoma
Dimpling
Flattening or inversion of the nipple
Caused by fibrosis in certain benign conditions, especially subareolar duct ectasia (usually bilateral)
Characteristic symmetrical appearance, usually with a central horizontal slit
In this case, the nipple can usually be manipulated by tension on the areolar margin to evert it
Malignant nipple inversion cannot be everted and is usually eccentric
