Writing Up the Physical Examination

Listed here are examples of the write-up for the examination of the breast.

• The breasts are symmetric, with both nipples pointing outward. The overlying skin is normal. No dimpling is present. There are no masses or discharge. Axillary examination reveals no lymphadenopathy.

• The left breast is slightly larger than the right. There is a serosanguineous discharge from the left nipple. When the patient presses her arms against her hips, a dimple is seen 4 cm from the nipple at the 2 o'clock position of the left breast. Palpation reveals a 2 x 3 cm stony mass under the area of dimpling. The mass appears fixed to the underlying muscle and overlying skin. Examination of the left axilla reveals numerous hard, fixed lymph nodes.

• The right breast is larger than the left. The skin is erythematous and warm to the touch, especially around the areola. The right nipple is inverted. No masses are felt. Dimpling cannot be appreciated. No axillary adenopathy is present.

• The breasts are pendulous and symmetric. Both nipples are everted. There are multiple round, freely mobile masses in both breasts, more on the right. The masses are 2 to 3 cm in diameter, elastic in consistency, and somewhat tender. Skin retraction is absent. No discharge is present. No axillary adenopathy is present.

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