General Examination
• Patient conscious, cooperative and oriented to time, place and person.
• Examination performed in a well-lit room with adequate exposure.
• Verbal consent obtained.
• Examination conducted in sitting and standing positions.
• Female attendant present throughout the examination.
General Physical Examination
Vitals
Pulse: __ /min
Blood Pressure:___mm of Hg
Respiratory Rate: ____/min
Temperature:____°F
BMI:____kg/m²
General Survey
Pallor: Present / Absent
Icterus: Present / Absent
Cyanosis: Present / Absent
Clubbing: Present / Absent
Generalized Lymphadenopathy: Present / Absent
Pedal Edema: Present / Absent
LOCAL EXAMINATION OF BREAST
Inspection
Breast
• Both breasts are equal/unequal in size.
• Visible swelling present/absent.
• Side involved: Right / Left breast.
• Quadrant involved: ______________.
• Size of swelling: ____ x ____ cm.
Nipple–Areola Complex
• Nipple–areola complex displaced/not displaced.
• Direction of displacement: ______________.
• Nipple retraction: Present / Absent.
• Cracks/Fissures/Eczema: Present / Absent.
• Nipple discharge: Present / Absent. (If discharge present , comment on it's colour, blood tinged or not, )
Areola
• Colour: ______________.
• Surface: Smooth / Irregular.
• Diameter:____cm.
Skin Over Breast
• Skin over swelling:_______
• Any Scar, Sinus, Dilated veins, Dimpling, Erythema, Hyperpigmentation, Ulceration, Fungating growth, Satellite nodules
Axilla and Surrounding Areas
• Any Visible axillary swelling: Present / Absent.
• Visible supraclavicular swelling: Present / Absent.
• Visible nodules over arm or thoracic wall: Present / Absent.
Dynamic Inspection
On raising arms above head, change in breast contour/lump prominence: Present / Absent.
Any Other Positive Inspection Findings: ______
Palpation
• Inspection findings confirmed by palpation.
• First palpate the Opposite Breast, any Significant findings present/absent.
Lump Characteristics
• Lump present in __ quadrant of Right/left breast.
• Size:___ x ____cm.
• Shape: ___
• Surface: Smooth / Nodular / Irregular.
• Margins: Well-defined / Ill-defined.
• Consistency: Soft / Firm / Hard.
• Tenderness: Present / Absent.
• Local rise of temperature: Present / Absent.
Mobility
• Mobile / Fixed.
• Vertical mobility: Present / Restricted.
• Horizontal mobility: Present / Restricted.
Skin Over Lump
• Skin pinchable / Not pinchable.
Fixity
• To skin: Present / Absent.
• To nipple: Present / Absent.
• To muscle: Present / Absent.
• To chest wall: Present / Absent.
Nipple Discharge
• Expressible discharge: Present / Absent.
• Nature (if present): ______________.
Lymph Node Examination
Axillary Lymph Nodes
• Palpable / Not palpable.
• If palpable:
- Number: __
- Size:____cm
- Consistency: Soft / Firm / Hard
- Tenderness: Present / Absent
- Mobility: Mobile / Fixed
Supraclavicular Lymph Nodes
• Palpable / Not palpable.
• If palpable:
- Number: ___
- Size:___cm
- Consistency: Soft / Firm / Hard
- Tenderness: Present / Absent
- Mobility: Mobile / Fixed
SYSTEMIC EXAMINATION
Cardiovascular System
• S1 and S2 heard normally.
• No added sounds/murmurs.
Respiratory System
• Bilateral air entry equal.
• No added sounds.
Abdomen
• Soft and non-tender.
• No organomegaly.
Breast Examination Summary
The patient is conscious and oriented to time, place and person. She is examined in a well-lit room, adequately exposed, in sitting and standing positions, after taking verbal consent, in the presence of a female attendant.
General physical examination revealed pulse ___/min, blood pressure ___ mmHg, respiratory rate ___/min, temperature ___°C and BMI ___. Pallor/Icterus/Cyanosis/Clubbing/Lymphadenopathy/Edema are present or absent accordingly.
On local examination of the breast, both breasts appeared equal/unequal in size. A solitary globular swelling of size approx ___ × _ cm is present in the ____ quadrant of the _____ breast. The nipple-areola complex of the right/left breast is displaced __________(upwards and outwards). The skin over the swelling is __________.
Other positive inspection findings include __________. No scar, sinus, dilated veins, dimpling, erythema, hyperpigmentation, ulceration, fungating growth or satellite nodules are noted.
The right/left nipple is retracted/not retracted. Both nipples are symmetrical with no cracks, fissures, eczema or discharge. The areola is __________ in colour, smooth and measures ___ cm in diameter. No visible nodules are seen over the arm or thoracic wall, and no visible swelling is noted in the axilla or supraclavicular fossa. On raising the arms above the head, there is no change in the shape of the breast or lump.
Inspection findings are confirmed by palpation. No significant findings are noted in the opposite breast. A solitary __________ shaped lump measuring ___ × _ cm is present in the _ quadrant of the ___ breast, having __________ surface, __________ margins and __________ consistency. The lump is non-tender, with no local rise in temperature, and is mobile/fixed in both vertical and horizontal directions.
The skin overlying the lump can/cannot be pinched. Fixity to skin, nipple, fascia, muscle and chest wall is present or absent accordingly. No nipple discharge is expressed.
Axillary and supraclavicular lymph nodes are palpable/not palpable.
On systemic examination, the cardiovascular system revealed normal S1 and S2. The respiratory system showed bilateral air entry with no added sounds. The abdomen was non-tender with no organomegaly.
