Examination checklist

    Breast examination

    A 24-step mark sheet for clinical breast examination with a chaperone — inspection in three positions, systematic palpation of both breasts, nipple, axilla and supraclavicular fossae — with a model presentation and the triple assessment that follows.

    Surgery
    Breast
    All colleges

    Mark sheet

    24 steps · 24 marks

    #StepWellPartlyNot
    1. 1Greets the examiner and the patient, introduces self, explains the examination and obtains consent1½0
    2. 2Offers and arranges a chaperone and ensures privacy1½0
    3. 3Exposes to the waist with the patient sitting upright, and asks about pain1½0
    4. 4Inspects with arms by the sides — size, symmetry, contour, visible lumps, skin changes1½0
    5. 5Inspects the skin for dimpling, tethering, peau d'orange, erythema, ulceration, nodules and scars1½0
    6. 6Inspects the nipples for retraction, deviation, discharge, eczema or destruction1½0
    7. 7Inspects with arms raised above the head1½0
    8. 8Inspects with hands pressed on the hips to contract pectoralis major1½0
    9. 9Asks the patient to lean forward if the breasts are large1½0
    10. 10Lies the patient at 45° with the hand behind the head on the side being examined1½0
    11. 11Examines the normal breast first1½0
    12. 12Palpates with the flat of the fingers systematically through all quadrants and the axillary tail1½0
    13. 13Palpates the retroareolar region and asks the patient to express any discharge1½0
    14. 14Describes any lump — site by quadrant and clock face with distance from the nipple, size, shape, surface, edge, consistency, tenderness, temperature1½0
    15. 15Tests fixity of the lump to the skin1½0
    16. 16Tests fixity to pectoralis major with the hand pressed on the hip, and to the chest wall1½0
    17. 17Examines the axilla with the patient's arm supported — medial, anterior, posterior, lateral walls and apex1½0
    18. 18Examines the other axilla1½0
    19. 19Palpates the supraclavicular and infraclavicular fossae and the cervical nodes1½0
    20. 20Examines the arm for lymphoedema1½0
    21. 21Offers to examine the liver, spine for tenderness, chest for effusion1½0
    22. 22Thanks the patient, helps her dress and maintains dignity throughout1½0
    23. 23Presents the findings clearly with a clinical TNM stage1½0
    24. 24States the need for triple assessment1½0

    Summary of findings

    I examined the breasts of a 45-year-old woman with a chaperone present. With her arms by her sides, the right breast is higher than the left, with skin dimpling in the upper outer quadrant that becomes more obvious with the arms raised. The nipples are normal. On palpation there is a single 4 × 3 cm lump in the upper outer quadrant of the right breast at 10 o'clock, 5 cm from the nipple. It is non-tender, hard, with an irregular surface and ill-defined edge. It is tethered to the skin but not fixed to pectoralis major or the chest wall. There are two firm, mobile right axillary lymph nodes in the anterior group, the larger 1.5 cm. The left breast and axilla and both supraclavicular fossae are normal. The liver is not enlarged, and there is no spinal tenderness. My clinical impression is carcinoma of the right breast, clinically T2 N1 M0. I would arrange triple assessment.

    Differential diagnoses

    LumpFeatures that point to it
    CarcinomaOver 35, hard, irregular, fixed, skin or nipple changes, axillary nodes
    FibroadenomaUnder 30, smooth, rubbery, highly mobile ("breast mouse")
    Phyllodes tumourOver 40, large, rapidly growing, smooth and lobulated, stretched shiny skin
    Cyst35–55, smooth, well defined, may be tender, can transilluminate
    Fat necrosisHistory of trauma, hard, may tether skin — mimics cancer
    Breast abscessLactating, red, hot, tender, fluctuant
    Periductal mastitisSmoker, subareolar mass, nipple retraction, fistula
    Tuberculous mastitisSinus, axillary nodes, systemic symptoms
    Lipoma, sebaceous cystSoft or superficial, attached to skin with a punctum

    Investigations

    Triple assessment — all three together:

    1. Clinical examination (as above)
    2. Imaging — ultrasound under 35 years; mammography (two views) plus ultrasound aged 35 and over; ultrasound of the axilla
    3. Pathology — ultrasound-guided core needle biopsy for histology, grade and receptors (ER, PR, HER2); FNA or core biopsy of abnormal axillary nodes

    If any of the three is suspicious, the lump is treated as malignant until proved otherwise.

    Treatment

    See Breast cancer staging and treatment and Benign breast disease.

    Examiner questions

    References

    • O'Connell PR, McCaskie AW, Sayers RD, eds. Bailey & Love's Short Practice of Surgery. 28th ed. Boca Raton: CRC Press; 2023.

    Updated September 18, 2026