Breast examination and how to present it

• A breast examination is an intimate examination: ask, explain, obtain proper consent, offer a chaperone, and stop whenever the patient asks. Nothing about it is routine to her. ^{[1] [3] [4]}
• It has three parts: inspection sitting up and lying, palpation with the flat pads of the fingers in a systematic pattern covering the whole breast, the tail and the axilla, and examination of the regional nodes. Only after those do you test for nipple discharge.
• Describe any lump in a standard way, in the same order every time, so that the next clinician can picture it without being there: position by clock face and distance from the nipple, then size, shape, consistency, surface, tenderness, mobility and fixity.
• Presentation starts with the most important finding, gives the measurable description, states the reassuring and concerning negatives, ends with an assessment and differential, then a plan.
• Breast awareness for women means knowing the normal look and feel of their own breasts; anyone who notes a change should get it checked, and symptom assessment should not be delayed because a woman "sees the doctor too late".
• The examination is the same in men in principle, with careful attention to the retroareolar tissue, and regional nodes and systemic signs are examined as for women.

By the end of this page you should be able to:

1. Prepare and carry out a breast examination in the correct order, including the examination of the tail and the axilla.
2. Describe a breast lump in standard language that another clinician can act on.
3. Interpret common normal and abnormal findings and red flags, and know what follow-up each demands.
4. Present normal and abnormal breast examination findings spoken and in the notes, and write clear example reports.
5. Teach breast awareness and demonstrate breast self-examination in plain language.
6. Adapt the approach for a male breast and for a woman who is pregnant, lactating, or has had prior breast surgery.

This page is about examining breasts and about describing what you find so that someone else can work from your report. It is written for a student at the bedside and in the exam room. It is not about diagnosis alone: an examination and a report that are clear are part of the treatment, because the same findings will be re-read months later by someone who was not in the room. Every clinician who meets a woman with a breast symptom uses the same sequence; this page teaches that sequence, the vocabulary, the meaning of each sign, and the way findings are turned into words.

The examination is intimate for most patients, and the context matters. A quiet, private room, a chaperone offered without assumption, a clear explanation of why the examination is needed, and the freedom to pause or stop at any time are part of the examination itself, not preparation for it. Many adverse events in breast practice begin as failures of communication or privacy rather than as failures of technique. The guideline statements below are taken from the sources listed in the front matter and are written in reader terms so that every member of a team can read the same report.

Preparation is the part that gives you permission to proceed. A rushed preparation makes the rest of the examination unsafe, because a patient who tenses, covers herself, or says "it is fine" when she does not mean it is not a good source of findings.

Tell her who you are, why the examination is needed, what it involves, and roughly how long it will take. If a student is to examine, obtain consent for that specifically, and give her the option to decline without discussion. Consent is continuous: she may withdraw it at any time without having to give a reason.

Offer a chaperone for every intimate examination, including the examination of the breast. ^[5] A chaperone should be trained for the role, familiar with the procedure, and able to observe both clinical correctness and the patient's comfort. ^[5] All patients undergoing intimate examination should be offered the presence of a chaperone. ^[5] The offer and her decision, including refusal, must be recorded in the notes, including the chaperone's identity when she accepts. ^[5] In practice, many women decline a chaperone while feeling reassured that they were allowed to choose. If you work alone, offer a woman staff member, a female clinician, a female nurse, or a family member she chooses, and document the arrangement.

Explain the examination clearly before touching: sitting inspection, lying palpation, the tail into the axilla, the regional nodes, and nipple examination. Tell her that you will keep her covered as much as possible, that you will tell her before you move her, and that she can ask questions at any point.

Wash hands and put on gloves if there is any discharge, skin break, or risk of body fluid. Seat her at 45 degrees, the usual position for chest examination, before you begin. Ask her to remove bra and upper garments behind a screen or curtain and to put on a short gown or a sheet across the chest. Keep the room warm. Check blood pressure if this is her first presentation, because anxiety can dominate the visit.

Use a bed with a firm surface, good light, and full privacy. Have a clean sheet available. Have a pre-printed documentation diagram for the breast (or draw one) so that a finding can be marked by position. Have a small ruler or tape measure, a pair of gloves, and tissue paper to hand. Needles and sampling equipment belong to the triple-assessment clinic, not to the initial examination.

Doing the examination in a fixed order protects against forgetting a region, especially the tail and the axilla, and makes reports comparable across clinicians. The order below is the one to learn and to use every time. Inspection comes first, because much of what you need to know about skin and symmetry disappears as soon as the patient lies down.

You may write the pattern of palpation as a vertical strip, a concentric circle, or a radial spokes pattern, but choose one and never miss the periphery or the axillary tail. A vertical strip pattern is usually the easiest to teach because it is the same pattern used during breast self-examination. ^[6]

Sit the patient at 45 degrees, both breasts uncovered and the upper body well lit, with the rest of the patient draped. First arms at sides, then hands on hips pressing forward (to contract the pectoral muscles), then arms raised above the head, and, if the breasts are large or pendulous, leaning forward so that the breast drape can be compared. For each position note:

• Size and shape. Minor asymmetry of size is normal. A new or marked asymmetry, a difference in height of the nipples, or a change in the lie of the breast can be the first sign of cancer, although it is not always. Many women have mild differences from puberty.
• Skin. Look for dimpling or tethering, change in skin texture, unilateral venous engorgement, redness, oedema and peau d'orange. Inflammatory breast cancer and mastitis look similar from the door; time course and tenderness matter.
• Nipples. Inversion present since development is common and may be bilateral. New unilateral inversion, persistent dermatitis, crusting, ulceration, or any discharge when she is not pregnant or breast-feeding is abnormal.
• Scars, lumps visible, or focal asymmetry of fullness.

Ask her to report any lump she found herself and to point to it. Always confirm with her own hand on the lump, because the site she describes is sometimes two or three centimetres away from the site you palpate.

Stand at the patient's side facing her. Use the flat pads of the two or three middle fingers of the examining hand, not the fingertips. Keep the fingers together, the wrist slightly flexed, and the fingers in contact with the skin throughout the movement. Apply gentle but deliberate pressure at each position before sliding to the next, so superficial and deep tissue is covered. Cover the whole breast surface, the tail extending into the axilla up to the clavicle, and the region under the nipple.

If one breast is symptomatic, examine the normal breast first so she learns what normal pressure feels like, then the symptomatic side.

Palpation can be done sitting for superficial lumps, but lies supine is needed for posterior tissue. Some clinicians prefer to palpate in the supine position with the arm on that side raised and supported, which flattens the breast against the chest wall and makes the tail more accessible. Either is acceptable; choose the position that gives the best contact, and, for very small breasts, the supine position is often unnecessary.

The axillary tail is the continuation of breast tissue from the upper outer quadrant, running through a roughly 3 to 4 cm wide strip into the axilla behind the pectoralis major. It can be palpable in many women as soft tissue high in the axilla. Failure to examine it means that a lesion is missed. With the patient sitting and the arm slightly abducted, slip the fingers high into the axilla behind pectoralis major, with the examining thumb on the anterior axillary fold. Sweep from high to mid axilla and to the chest wall. Then examine the axillary nodes (see below). After the axilla, return and palpate the medial breast, the inframammary fold, and the nipple; many cancers lie in the medial or subareolar tissue.

Examine the axillary, supraclavicular and infraclavicular nodes with the patient seated or at 45 degrees. For axillary nodes, support the patient's relaxed arm at the wrist, slightly abduct it, and place the other hand deep into the axilla with fingers pointing toward the apex. Sweep downward over four regions:

1. Along the chest wall behind pectoralis major (anterior and mid-axillary).
2. Along the posterior axillary wall (scapular region).
3. High in the axilla to the axillary apex and axillary vein.
4. Along the upper arm (brachial).

Then examine the infraclavicular fossa and the supraclavicular fossa on both sides, because nodes there are the clavicular station and relate to mediastinal and neck drainage. Record the size, number (single, or multiple), mobility (mobile or fixed), consistency (soft, rubbery, firm, hard) and tenderness of every node found. Nodes that are hard, large, fixed to skin or deep structures, or found above the clavicle require urgent referral in the context of a breast complaint.

Inspect both nipples including their base, eversion and the skin of the areola. Look carefully for Paget change (a persistent eczematous patch usually limited to the nipple), crusting, excoriation and ulceration. If a discharge has been reported, expression is part of the examination. First offer to let the patient express it; if she declines, use the pads of the index finger and thumb to compress from the periphery toward the nipple, working around the clock so any discharging duct is localised. Note:

• Spontaneous versus expressed discharge. Spontaneous is more clinically relevant.
• Unilateral versus bilateral.
• Single versus multiple ducts.
• Colour and quality: clear, serous, milky, green, yellow, brown or bloody.
• Associated features: lump, pain, tenderness, or skin change.

Try to see the discharge on a pad or a clean swab. Bloody, persistent, single-duct and unilateral discharge needs assessment in a breast clinic and is reported as a red flag even when the examination otherwise looks normal. Milky discharge in a non-lactating woman needs an endocrine workup for prolactin excess and a pregnancy test where appropriate. If the mass is painful, press gently and stop if she withdraws. If the breast is inflamed, swab the discharge and document tenderness. Attempts to express discharge should always be gentle; pain on expression or localising pain needs to be recorded rather than maximised.

Repeat palpation in the other breast for comparison, even if it seemed normal, because symmetry is information. Complete all documentation before you help her dress again; a finding that exists only in memory rarely gets recorded. A simple diagram with position marked by clock face and distance from the nipple in centimetres allows another clinician to either find the same finding or confidently say that it has changed.

The table below is written as a reference to be used in the room: sign, how to elicit it, and what it means. A sign gains meaning from the history; read this page with the breast cancer and benign breast disease pages, and do not make a diagnosis from a sign list alone. Features overlap, and any single sign can be innocent.

Presentation is a written report and a verbal one. It should always be organised in the same order, so that the listener can make a second diagnosis from your words alone. Lead with the positive or important finding, because that is what the case turns on; then the standard description; then the negatives that the listener would otherwise worry about; then an assessment and a differential; then what you want done.

1. One-line summary. Who the patient is, in simple terms, and the most important finding. Example: "A 42-year-old woman with a three-month history of a lump in her right breast; examination finds a hard lump at 2 o'clock, 3 centimetres from the nipple."
2. General state. Well or unwell, cachectic, distressed, in pain.
3. Inspection. Size, shape, skin, nipples, and any visible change; both breasts.
4. Palpation. Dominant lump description first, then other lumps or thickening; note the background breast texture (nodular, smooth, tender).
5. Nipple, discharge, and skin. What is reported, what you found, and what you expressed.
6. Regional nodes. Axillary and supraclavicular, size and character.
7. The important negatives. No skin dimpling, no nipple retraction, no fixation, no nodes, no discharge (if you checked). State these because they are what reassures or alarms.
8. Assessment. Plain summary: "this clinically feels benign as far as today, but needs triple assessment", "suspicious characteristics, refer urgently", "inflammatory change, try antibiotics and review", or "normal examination; awareness advice".
9. Differential and plan. One or two sensible differentials and the next step requested.

Use this pattern every time; it mirrors what will be needed for triple assessment and for a mammogram request:

1. Position. Clock face (for example 2 o'clock) and the distance from the nipple in centimetres. State "upper outer quadrant" as well if it helps. State which breast and, for very lateral lesions, whether it is in the axillary tail.
2. Size. Longest and shortest dimensions, in millimetres or centimetres.
3. Shape. Round, oval, irregular, lenticular, or stellate.
4. Consistency. Soft, cystic (fluctuant), firm and rubbery, or hard.
5. Surface. Smooth, lobulated, or irregular.
6. Tenderness. Tender or non-tender.
7. Mobility. Mobile in all planes, mobile against skin but fixed to deep tissue, fixed to skin and to deep tissue.
8. Skin and fixation. Tethered, skin dimpled over it, not tethered, peau d'orange overlying or absent.
9. Nipple relationship. Extruding, retracting, untouched.
10. Other. Cystic change, bruising, old scars, surrounding thickening.

Write the report in full sentences in the same order. Abbreviations are a kindness now and a mystery later: write "3 cm x 2 cm" but avoid personal shorthand. Include a diagram with the mass marked. Mark the dimensions, the position on the clock, and whether the mass is cystic or solid if you have used ultrasound notes. State if the patient was distressed, and always state the proportion (for example, "6 x 6 cm") rather than other adjectives alone.

Say "no node was palpable" rather than "the nodes were normal", because it records what you know rather than what you imply. State "no discharge expressed, patient declined expression" rather than "no discharge". Note if the breast was too tender to examine fully, or if the examination was painful.

These reports are illustrative and all patient details are invented. They are given so you can hear how the findings sound when spoken aloud and how they look in the notes. You may quote or adapt the form, not the content.

"A 30-year-old woman attends for reassurance before a work trip. She has no breast symptoms and no family history of breast cancer. On inspection the two breasts are symmetrical, the skin is normal, there is no dimpling or nipple change. Palpation is comfortable, and no lump or thickening is found in either breast, in the tail, or in the axilla. The supraclavicular fossae are empty. No discharge can be expressed. In summary, the examination is normal. I will explain breast awareness and advise her to return if she notices any lump, nipple change, skin change, or any new symptom." ^[2]

Normal examination, in the notes: "Bilateral symmetrical breasts, no skin or nipple change. No lump or thickening palpated anywhere in either breast or its tail. Axillae, supra and infraclavicular fossae bilaterally empty. No discharge expressed. Impression: normal clinical breast examination; breast awareness advice given, written information provided."

"A 24-year-old woman presents with a four-month history of a smooth, very mobile lump in her left breast, painless. She is otherwise well. Inspection is unremarkable, no skin or nipple change and no asymmetry. There is a 2 cm round, smooth, rubbery, mobile lump at 2 o'clock, 3 centimetres from the nipple, non-tender and not fixed to skin or deep tissue. No other lumps. The nipple expresses no discharge. Axillary examination is normal. I think this is likely a fibroadenoma, although a triple assessment is needed to be sure, and ultrasound plus core biopsy if clinically indeterminate. She is otherwise well, and I will explain that fibroadenomas are benign and do not turn into cancer." ^[2]

"A 58-year-old woman attends with a six-week history of a non-tender lump in her right breast, growing since she found it. Inspection shows the right breast is slightly swollen, with a faint area of skin dimpling and retraction of the nipple when her arms are raised. There is a 2.5 centimetre, irregular, hard lump at 10 o'clock, 4 centimetres from the nipple, fixed to skin and deep tissue, with overlying skin tethering. The nipple discharge is blood-stained and expressed from a single duct. The right axilla is firm with one 2 centimetre hard, fixed node. The left breast and axilla are normal. This is suspicious, and she needs same-day assessment, mammography and ultrasound with ultrasound-guided biopsy. Inflammatory breast cancer is high in my differential if there is early erythema and peau d'orange; metastatic disease changes the way we plan the first tests."

"A 36-year-old woman is eight weeks after delivery and has a red, hot, tender right breast, febrile to 38.6 degrees. Inspection shows a swollen, erythematous upper outer quadrant, oedematous with early peau d'orange. There is no obvious lump, but a focal area of induration at 3 o'clock, 3 centimetres from the nipple. Axillary node is tender and mobile. The left breast is normal. She is lactating, and improvement over 48 hours on antibiotics and continued drainage would be expected if this is mastitis. If it does not improve, the same-day breast clinic must reconsider inflammatory breast cancer. I shall document this decision now, because it shows reasoning in the event that either outcome happens."

"A 46-year-old man attends with a firm, slightly tender, centrally placed lump under the areola of the right breast. Both areolae are symmetrical, the right shows a smooth, firm, disc-like 3 cm pad of tissue behind the areolar edge. No skin change, no nipple discharge, no axillary node palpable; there is no generalised gynaecomastia and he takes anabolic steroids. The likely diagnosis is physiological gynecomastia from the drug exposure, with normal examination otherwise. If, instead, the mass were hard, irregular, eccentric, fixed, or associated with nipple retraction or skin change, male breast cancer would need biopsies and oncology involvement."

• Examining only the breast that hurts, and letting the other side go entirely.
• Missing the axillary tail, which extends high into the axilla, or the medial and subareolar tissue.
• Using fingertips instead of the flat pads, which misses soft lesions and causes unnecessary pain.
• Thinking that a normal mammogram makes a clinical finding disappear; a palpable lump needs assessment even when imaging and clinical examination disagree.
• Palming a lump with the whole hand, or using the thumb to poke, distorts and brakes findings.
• Forgetting to inspect with arms raised and hands on hips against resistance, which is when tethering and retraction appear.
• Hiding doubt in the notes; a report that says "probably benign" without next steps is a no-action plan.
• Expressing discharge roughly, or forgetting to look at it when she brought it; ask her to express it first.
• Not offering a chaperone, or not recording her choice.
• Describing a lump with adjectives rather than measurements; "large" is not data.
• Forgetting to record pain or inability to complete the examination.
• Missing axillary nodes, or not examining the supraclavicular fossa.
• Relying on "normal ultrasound" to stop the assessment; assessment is clinical plus imaging plus pathology, agreed together.
• Not documenting. A second examiner who cannot reproduce a finding needs to know whether the first one was real.