December 30, 2023

Embassy of Japan in the Philippines

2627 Roxas Boulevard, Pasay City, 1300

Metro Manila, Philippines

Dear Sir/Madam:

I am writing this letter to explain why I am unable to present an Income Tax Return (ITR) for my
visa application.

My ITR is still undergoing processing as per writing. The target is early February 2024.

Thank you for reviewing my application.

Respectfully yours,

Right Axilla. Use your left hand to examine the right axilla.
If the central nodes feel large, hard, or tender, or if there is a suspicious lesion in
the drainage areas for the axillary nodes, palpate for the other groups of axillary
lymph nodes:
■ Pectoral nodes—grasp the anterior axillary fold between your thumb and
fingers, and with your fingers, palpate inside the border of the pectoral
muscle.
■ Lateral nodes—from high in the axilla, feel along the upper humerus.
■ Subscapular nodes—step behind the patient and, with your fingers, feel inside
the muscle of the posterior axillary fold.
■ Infraclavicular and supraclavicular nodes—Also re-examine the infraclavicular
and supraclavicular nodes.
Special Techniques
Examination of the Mastectomy or Breast Augmentation
Patient. The woman with a mastectomy warrants special care on examination.
Inspection. Inspect the mastectomy scar and axilla carefully for any
masses, unusual nodularity, or signs of inflammation or infection. Lymphedema
may be present in the axilla and upper arm from lymph drainage interrupted by
surgery.
Palpation. Palpate gently along the scar—these tissues may be unusually
sensitive. Palpate the breast tissue and incision lines bordering breast augmentation or
reconstruction. Use a circular motion with two or three fingers. Pay
special attention to the upper outer quadrant and axilla. Note any enlarged
lymph nodes.
Instructions for the Breast Self-Examination. For interested or
high-risk patients, instruct the patient about how to perform the BSE. A high
proportion of breast masses are detected by women examining their own breasts.
For screening, the BSE has not been shown to reduce breast cancer mortality, but
may promote health awareness and earlier reporting of breast changes or masses,
which may reduce unnecessary testing and biopsies compared to monthly selfexamination.7,41
The BSE is best timed 5 to 7 days after menses, when hormonal
stimulation of breast tissue is low.
Nodes that are large (≥1 to 2 cm) and
firm or hard, matted together, or fixed
to the skin or underlying tissues suggest malignancy.
Masses, nodularity, and change in
color or inflammation, especially in
the incision line, suggest recurrence
of breast cancer.
EXAMPLES OF ABNORMALITIES442 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A
NDHISTORYTAKING
TECHNIQUES OF EXAMINATION
Patient Instructions for the Breast Self-Examination—
American Cancer Society
Lying Supine
1. Lie down with a pillow under your right shoulder. Place
your right arm behind your head.
2. Use the finger pads of the three middle fingers on your
left hand to feel for lumps in the right breast. The finger
pads are the top third of each finger. Make overlapping,
dime-sized circular motions to feel the breast tissue.
3. Apply three levels of pressure in each spot: light, medium, and firm, using firmer pressure for
tissue closest
to the chest and ribs. A firm ridge in the lower curve
of each breast is normal. If you’re not sure how hard to
press, talk with your health care provider, or try to copy
the way the doctor or nurse does it.a
4. Examine the breast in an up-and-down or “strip” pattern. Start at an imaginary straight line
under the arm,
moving up and down across the entire breast, from the
ribs to the collarbone, until you reach the middle of the
chest bone (the sternum). Remember how your breast
feels from month to month.
5. Repeat the examination on your left breast, using the
finger pads of the right hand.
6. If you find any masses, lumps, or skin changes, see your
clinician right away.
Standing
1. While standing in front of a mirror with your hands
pressing firmly down on your hips, look at your breasts
for any changes of size, shape, contour, or dimpling, or
redness or scaliness of the nipple or breast skin. (The
pressing down on the hips position contracts the chest
wall muscles and enhances any breast changes.)
2. Examine each underarm while sitting up or standing and
with your arm only slightly raised so you can easily feel
in this area. Raising your arm straight up tightens the
tissue in this area and makes it harder to examine.
Adapted from the American Cancer Society. American Cancer Society. Breast awareness and
self-exam. Updated April 9, 2015. Available at http://www.
cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-
early-detection-acs-recs-bse. Accessed May 7, 2015.C H A P T E R 10 | The Breasts and Axillae
443
RECORDING YOUR FINDINGS
Note that initially you may use sentences to describe your findings; later you will
use phrases.
Recording Your Findings
These findings suggest possible
breast cancer.
EXAMPLES OF ABNORMALITIES
Recording the Breasts and Axillae Examination
“Breasts symmetric and smooth without nodules or masses. Nipples without
discharge.” (Axillary adenopathy usually included after Neck in section on
Lymph Nodes; see p. 266.)
OR
“Breasts pendulous with diffuse fibrocystic changes. Single firm 1 × 1 cm mass,
mobile and nontender, with overlying peau d’orange appearance in right breast,
upper outer quadrant at 11 o’clock, 2 cm from the nipple.