Checklist

WIPER

• A chaperone will help the patient get changed into an examination gown in a private area.

• The patient is positioned sitting on the edge of the bed with hands resting on hips.

• The breasts are exposed only when the examination begins.

Physiological parameters

General

• Weight loss

• Radiotherapy tattoos or Hickman line scar (for chemotherapy)

• Donor site scars: TRAM or DIEP flap (lower abdomen), LD flap (back) or other scars (e.g. gluteal or transverse myocutaneous gracilis)

• Bra: prosthetic or cosmetic inserts suggestive of breast asymmetry, bra cup size

Inspection

• Chest wall/spine/shoulder: symmetry/deformities (crucial to apparent breast appearance)

• Breast: volume, symmetry, shape, projection, chest wall position

• Nipples: deviation, retraction, inversion, discharge, Paget's disease, eczema

• Skin: scars, mammary fistulas, erythema

• Soft tissues: lumps, skin dimpling, peau d'orange, cancer en cuirasse, ulceration

• Haagensen manoeuvre: press arms on hips, lift hands behind head, slowly lower arms

• Axillae: masses, SLNB or ANC scars

• Supraclavicular fossae: swelling/masses

• Arms: lymphoedema (comment on any compression garment), muscle wasting

Palpation

• Breast: masses, tenderness:

•four breast quadrants (upper/lower, outer/inner)

•nipple and retroareolar tissues

•axillary tail of Spence

• Nipple: discharge

• Axilla: lymphadenopathy (five sites per side), accessory breasts

• Lateral chest wall: port sites for breast expander implants

To complete the examination…

• Neck/supraclavicular fossae: lymphadenopathy

• Spine: tenderness

• Abdomen: hepatomegaly

• Chest: pleural effusions