Breast disease- History + Exam

Question 1

Presenting complaint

Answer 1

Lump
Nipple Discharge
Pain
Hormonal history
Past breast history
RFs for breast problems
General health + other comorbidities

Question 2

Lump

Answer 2

Size
Shape
When appeared
How you found it
Change over time

Question 3

Nipple discharge

Answer 3

Uni or bilateral
Single or multi duct
Spontaneous or simulation
Colour
Pregnancy or breastfeeding?

Question 4

Pain

Answer 4

Onset
Site
Severity
Relieving or exacerbating factors
Relationship of symptoms to menstrual cycle
Radiation

Question 5

Hormonal history

Answer 5

Puberty
Menstruation history--> regular, heavy, painful, PMS
Contraceptive history
Pregnancy history
Breastfeeding history
Menopause

Question 6

Past breast history

Answer 6

Previous breast cancer, visits or breast clinic or breast surgery

Question 7

RFs for breast problems

Answer 7

FH
Alcohol
Weight
Smoking

Question 8

General health + other comorbidities

Answer 8

Medications –> especially hormones

Other medical conditions

Question 9

RF History- FH

Answer 9

Ask about which relatives (both maternal + paternal)
–> 1st degree= mother, sister, daughter
–> 2nd degree= grandmother, aunt, niece
What age were they diagnosed
What their diagnosis was
Having extensive FH with cancer at early age increases risk of genetic mutations that predispose to BC

Question 10

Genetic mutations

Answer 10

BRCA1, BRCA2- tumour suppressor gene involved in repair of damaged DNA
Lifetime risk of BC for BRCA1= 40-65%
Lifetime risk of BC for BRCA2= 40%
TP53- tumour suppressor gene involved in cell cycle regulation, apoptosis and DNA repair

Question 11

RF history- Age

Answer 11

Risk increases with age

Question 12

RF history- Pregnancy

Answer 12

Never having child or having child after 30 increases risk

Question 13

RF history- BF history

Answer 13

Protective

Question 14

RF history- age of menarche

Answer 14

Earlier menarche increases risk

Question 15

RF history- age of menopause

Answer 15

Late menopause increases risk

Question 16

RF history- HRT

Answer 16

Increases risk

Question 17

RF history- Radiation history

Answer 17

Includes any chest x rays or nuclear medicine scans that may have been performed
Even small doses can increase risk

Question 18

RF history- Weight history

Answer 18

being overweight, especially after menopause, increases BC risk

Question 19

RF history- Alcohol

Answer 19

Increases risk of BC in dose dependent manner

Question 20

Breast Exam- Observation

Answer 20

Look at breasts while patient is standing with arms by side, raised above head + pressed against hips
Assess symmetry
Look at contours
Observe colour/texture of skin
look at nipples + assess symmetry, if inverted, any discharge + any abnormalities

Question 21

Breast exam- palpation

Answer 21

Patient lie flat with arm raised + on shoulder + forehead
Use finger rotary movement, start in axilla, move to mid-axillary line + then back up a line more medial to this and then down line more medial to this + so on
Examine nipple- lumps
Feeling for lumps- continue all way to sternum
Lumps- size, shape, constituency, tenderness, mobility etc

Question 22

Breast exam- axillary LNs

Answer 22

Relax arm + hold at elbow with one hand
With other hand feel for central LNs against chest wall + in apex of axilla
Any lumps described same way as breast lumps
If central nodes found, also feel for pectoral, posterior axillary + lateral
Examine supra and infraclavicular fossa

Question 23

Malignant breast masses

Answer 23

Hard
Painless (90%)
Irregular margins
Fixation to skin or chest wall
Skin dimpling may occur
Discharge- bloody, unilateral
Nipple retraction may be present

Question 24

Benign breast masses

Answer 24

Consistency- firm or rubbery
Often painful
Regular or smooth margins
Mobile and not fixed
Skin dimpling unlikely
Discharge- no blood, bilateral, green or yellow
No nipple retraction