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Atlas of breast cancer early detection

Clinical breast examination (CBE) – Documentation


Document the findings for the left and the right breasts separately using the following list:
  • Shape of the breast
  • Skin over the breast
  • Nipple discharge: absent/present. If present, describe its colour, thickness, odour, and amount
  • Breast lump: absent/present. If present, describe the following:
    • Number:
    • Location by quadrant of the breast: UIQ/UOQ/LIQ/LOQ/central
    • Size in centimetres
    • Consistency: soft/firm/hard
    • Surface: smooth/irregular
    • Mobility within the breast tissue: yes/no
    • Mobility over the underlying muscles: yes/no
  • Axillary lymph nodes: not palpable/palpable. If palpable, describe
    • Number of nodes:
    • Consistency of the nodes: soft/firm/hard
    • Nodes fixed to each other: yes/no.
Complete the CBE by noting the probable clinical diagnosis and the action to be taken for the findings, if any, with the form for reporting the findings of the CBE.

If possible, a line diagram showing the position and size of the lump with the axillary nodes should accompany the CBE report.


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