Breast Lump Flashcards
A 25 year old female presented to your fertility clinic with complaints of breast lumps in her breast. Clerk her on her presenting complaints.
GRIP
BIODATA
REPRODUCTORY PROFILE:
When was the first day of your last menstrual period.
Have you ever been pregnant before
When was your last child born
It’s states here that you presented with lump in your breast, is that right?
Presenting complain 5Cs
Doctor
How long have you noticed the lump
Did it start suddenly or gradually
Has it been getting worse or better since you noticed it?
Where is the lump located, is it on the left or right or both breast?
Is it movable or fix
Is it painful to touch
Is there any change in the lump during ovulation, pregnancy, menstruation, breastfeeding or childbirth?
Any change on the breast skin
Any ulceration, any change in color
Any nipple changes? Any retraction?
Any discharge? Like blood, milk, or pus
Any nipple inversion?
Have you noticed any weight loss?
Any swelling in your armpit?
Any changes in skin color?
Any weakness and easy fatigue
CAUSE
Has there been any history of breast pain, swelling, and fever ( mastitis, breast abscess)
Has there been weight loss, low grade fever, drenching night sweating ( TB,
Malignancy)
Do you eat fatty/ processed food, drink alcohol or smoke ( malignancy)
Do you use oral contraceptives ( medication)
Any history of similar conditions in your families ( hereditary)
Has the breast lump happened in the past ( reoccurrence)
At what age did you start menstruating ( menarche )
COMPLICATIONS
Have you noticed easy fatigue, loss of appetite and weight loss ( malignancy)
Any history of coughing, difficulty breathing, shortness of breath ( lung metastasis)
Any history of bone pain, especially your lower back or spine ( bone metastasis)
Any yellowish of your eyes and skin , loss of appetite and abdominal swelling ( liver metastasis)
Any headache, convulsions, visual changes ( brain metastasis)
CARE SO FAR
What have you done since you noticed the lump
Have you visited any prayer house, pharmacy or hospital
Have you taken any medication
Have you done any investigations
OBSTETRICS HISTORY
Have you been pregnant before
How many children do you have
Was the pregnancy spontaneously conceived or through assisted means
Did you have any event during your pregnancy
How long did your carry the pregnancy ?was it up to term
What was the mode of delivery? Was it vaginal or caesarean secion
vaginal was it spontaneous or induced
How long did the labor last
Did you have any complication eg bleeding
How many days did you stay in the hospital
Is the child alive and well
GYNECOLOGY HISTORY
At what age did you first see your menstrual period
How many days do you bleed
Do you see your period every month
Do you know the length of your cycle
Do you usually have menstrual cramps how many pad do you use
Do you have painful sexual intercourse
Have you had any miscarriage or abortion in the past
Are you aware of contraceptives, do you use any?
Have you heard of pap smear ?
have you done one?
PAST MEDICAL HISTORY
Have you had similar symptoms in the past
Do you have any chronic illness like hypertension, epilepsy, asthma. diabetes or sickle cell disease
Have you had any blood transfusion, surgery, or hospitalization in the past?
FAMILY HISTORY
is there any one in your family with similar diseases ( HEAD)
SOCIAL HISTORY and Drug history
Do your drink alcohol, do you smoke Do vou have multiple sexual partners
Are you on any long term medication
Are you on any current medication
Do you have drug or food allergies
REVIEW OF SYSTEM
Ma. just to be sure I didn’t miss out any symptoms . I would like you to say yes or no to the following questions
UNS: any headache, any blurry vision , any loss of consciousness
ENDO: any neck swelling? Do you feel hot when other are cold.
any unexplained weight loss or weight gain
RESP: any cough, chest pain, difficulty breathing
CVS: are you aware of your heart beat, have you noticed that you are easily out of breathe any swelling on your bodv
especially the lower limbs
DIGESTIVE: and nausea, vomiting, and constipation, blood in stool
GUS: bloody urination, abnormal discharge . increased frequency in urination
MSS: any bone pain, joint pain, and difficulty walking, skin rash
