Physical Examination for Surgeons: Examination of the breast

Checklist WIPER • A chaperone will help the patient get changed into an examination gown in a private area. • The patient is positioned sitting on the edge of the bed with hands resting on hips. • The breasts are exposed only when the examination begins. Physiological parameters General • Weight loss • Radiotherapy tattoos or Hickman line scar (for chemotherapy) • Donor site scars: TRAM or DIEP flap (lower abdomen), LD flap (back) or other scars (e.g. gluteal or transverse myocutaneous gracilis) • Bra: prosthetic or cosmetic inserts suggestive of breast asymmetry, bra cup size Inspection • Chest wall/spine/shoulder: symmetry/deformities (crucial to apparent breast appearance) • Breast: volume, symmetry, shape, projection, chest wall position • Nipples: deviation, retraction, inversion, discharge, Paget's disease, eczema • Skin: scars, mammary fistulas, erythema • Soft tissues: lumps, skin dimpling, peau d'orange, cancer en cuirasse, ulceration • Haagensen manoeuvre: press arms on hips, lift hands behind head, slowly lower arms • Axillae: masses, SLNB or ANC scars • Supraclavicular fossae: swelling/masses • Arms: lymphoedema (comment on any compression garment), muscle wasting Palpation • Breast: masses, tenderness: •four breast quadrants (upper/lower, outer/inner) •nipple and retroareolar tissues •axillary tail of Spence • Nipple: discharge • Axilla: lymphadenopathy (five sites per side), accessory breasts • Lateral chest wall: port sites for breast expander implants To complete the examination … • Neck/supraclavicular fossae: lymphadenopathy • Spine: tenderness • Abdomen: hepatomegaly • Chest: pleural effusions Examination notes How are breast lumps assessed? Any new breast lump requires triple assessment. Symptomatic patients should be assessed in a one-stop breast clinic. What does the triple assessment involve? Clinical: examination by a surgeon Imaging: breast ultrasound (women under 40 years) or mammography (women 40 years or older) Histology: fine-needle aspiration (FNA) or core biopsy Each is scored 1–5 (1 = low, 5 = very high risk).