Knowledge · Clinical Examination

Breast Examination for MRCS Part B: Positions, Quadrants and Triple Assessment

By Dr Richard Miller, MBChB FRCS with the MRCS Part B Questions Team · Reviewed 15 September 2026

In brief

Inspect the breasts in four positions, palpate the normal side first through all four quadrants and the axillary tail, examine the nipple and the regional nodes, then offer the components of triple assessment.

Breast examination is inspection in four positions, then palpation of the normal breast first through all four quadrants and the axillary tail, then the nipple, then the axillary, supraclavicular and infraclavicular nodes. Ask where the area of concern is before you look, and finish by offering the three components of triple assessment.

Key takeaways

The GMC lists breast examination as an intimate examination, so consent and a chaperone come first.
Ask the patient where the area of concern is before you look.
Inspect sitting with arms by the side, raised above the head, and with hands pressed on the hips.
Tumours most commonly affect the upper outer quadrant of the breast.
Triple assessment is clinical examination, imaging and needle biopsy in one visit.

How is this station marked in MRCS Part B?

A physical examination station is marked out of 20 across four domains: clinical and technical skill carries 8 marks, and clinical knowledge and its application, communication, and professionalism carry 4 marks each. The examiner also gives the station a separate global rating of pass, borderline or fail.

Two things follow from that split. More than half the marks sit outside your knowledge of the condition, so a silent, technically correct examination scores poorly. And you are signalled at six minutes of the nine to present your findings, so the sequence has to finish inside six.

How do I start the breast examination?

Gel your hands in view of the examiners, introduce yourself, explain what the examination involves and why it is needed, tell the patient they can ask you to stop at any time, offer a chaperone and gain consent.

Then ask the single most useful question at this station: where is the area you are worried about, and how long has it been there.

What are the four inspection positions?

Sit the patient on the edge of the couch with the upper half exposed, and look from the front in each position in turn.

Arms relaxed by the sides, for baseline asymmetry and obvious masses.
Arms raised above the head, which stretches the skin and brings out tethering and dimpling.
Hands pressed firmly on the hips to contract pectoralis major, which shows fixity to the chest wall.
Leaning forward, which lets a pendulous breast hang free and shows asymmetry of contour.

Look for asymmetry, a visible mass, skin dimpling, peau d'orange, erythema, scars, nipple inversion and the eczematous nipple change of Paget's disease.

How do I palpate the breast?

Lie the patient back at 45 degrees, rolled slightly away from the side you are examining, with that arm behind the head. Examine the normal breast first.

Use the flat of the fingers and a systematic pattern, either concentric circles or vertical strips, covering every part of the breast.
Include all four quadrants and the axillary tail of Spence, which extends towards the axilla.
Palpate behind the nipple and areola last, asking permission first because it is sensitive.
Ask about and gently express any nipple discharge rather than squeezing repeatedly.

Describe any lump by site, size, shape, surface, consistency, tenderness, mobility, and whether it is fixed to skin or to the underlying muscle when the patient tenses pectoralis major.

How do I examine the axilla and regional nodes?

Take the weight of the patient's arm in your own so the pectoral muscles relax, then insert your fingers high into the axilla and draw them down against the chest wall.

Examine all five axillary groups: apical, central, anterior, posterior and lateral.
Then palpate the supraclavicular and infraclavicular fossae.
Describe nodes by number, size, consistency, tenderness and whether they are matted or fixed.

What should I offer at the end?

Say that you would complete the examination by looking for metastatic disease, and name where you would look.

Percuss and palpate the spine for bony tenderness.
Auscultate the lung bases.
Palpate the abdomen for hepatomegaly.
Cover the patient and thank her before presenting.

What is triple assessment, and what does NICE say about referral?

**Triple assessment** is clinical examination, imaging with mammography or ultrasound or both, and tissue sampling by core biopsy or fine needle aspiration, performed in a single one-stop clinic. Each component is scored, and a discordant result drives further investigation.

NICE NG12 recommendation 1.4.1 is to refer using a suspected cancer pathway referral anyone aged 30 and over with an unexplained breast lump with or without pain, or aged 50 and over with discharge, retraction or other changes of concern in one nipple only. Recommendation 1.4.2 says to consider the same pathway for skin changes that suggest breast cancer or an unexplained axillary lump aged 30 and over, and 1.4.3 says to consider non-urgent referral under 30.

What are the most common mistakes at this station?

Starting with the symptomatic breast, so there is no normal comparison and the patient is examined at her most anxious.
Using only one inspection position and missing tethering.
Forgetting the axillary tail, which lies outside the four quadrants people actually palpate.
Squeezing the nipple repeatedly without asking.
Quoting a two week wait without being able to state the age thresholds in NG12.
Failing to offer a chaperone, which the GMC treats as a requirement rather than a courtesy.

MRCS Part B Questions has a breast examination station with a marked checklist at /Sample-Questions. Reviewed and updated 15 September 2026.

Key evidence

Suspected cancer: recognition and referral (NG12), recommendations by site of cancer — NICE (2023)
Intimate examinations and chaperones — General Medical Council (2024)
Breast Exam — Stanford Medicine 25
Trends in the distribution of breast cancer over time in the southeast of Scotland — Ecancermedicalscience (2014)

FAQ

Which breast do I examine first?

The normal one. It gives you a baseline for that patient's breast tissue, which varies enormously, and it lets the patient feel the pressure you are using before you touch the area she is worried about. Say out loud that you are starting with the normal side.

Why is the upper outer quadrant important?

It is the commonest site of breast carcinoma, and it is also the part most often palpated carelessly because it merges into the axillary tail. Cover it deliberately and continue your palpation up into the tail of Spence towards the axilla.

What does skin dimpling tell me?

Dimpling indicates tethering of the skin to an underlying lesion, classically through Cooper's ligaments, and it raises the suspicion of malignancy. It is often invisible with the arms down, which is why you inspect again with the arms raised and with the hands pressed on the hips.

Do I need a chaperone if the examiner is present?

Yes, you should still offer one and explain the role, because the offer is part of the examination you are being marked on. The GMC says a chaperone should usually be a health professional who can stay for the whole examination and see what you are doing.

What is a one-stop breast clinic?

It is a clinic where the three components of triple assessment happen in a single visit, so that examination, imaging and any needle biopsy are completed the same day. It shortens the time to diagnosis, and naming it shows the examiner you understand the pathway and not only the physical signs.

The MRCS Part B Questions Team

Written and maintained by doctors who have sat and scored well at this interview, and reviewed against the current published guideline in each case. Guidance changes — check the source before you rely on a threshold.

Last reviewed 15 September 2026

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