Breast

Case – History Taking

- Dr. Ankit Chandra


1. Patient details
• Name –
• Age –
• Occupation –
• Educated up to –
• Hailing from (address) –
• Socioeconomic status -

2. Chief complain
• Lump in the Right/Left breast for ____ months /years
• Pain in Right/Left breast for ____ months /years
• Discharge from the left/right nipple for ____ months /years
• Retraction of right/left nipple for ____ months /years


3. History of presenting illness (HOPI)

History of Lump
• Patient was apparently well ___ months back , when she noticed a lump in the
Right/left breast while taking bathe .
• Onset – insidious
• It was a small lump was started at ___months back and now has reached to present
size. (*rate of growth)
• Associated with any pain? (*Mastitis) Discharge ?
• Any history of swelling/lump in opposite breast / axilla ?

HISTORY & EXAMINATION FOR BREAST CASE| Dr. Ankit Chandra

 • History of any ulcer over the lump ?
• Retraction of Nipple ?
• h/o Trauma (direct blow/seat belt) – Hematoma , Traumatic fat necrosis
• h/o loss of weight/appetite - occur only last stage of Breast ca, TB breast


3a) History of Pain
• Onset – sudden/ gradual
• Site – U/L or B/L
• Duration -
• Nature of pain –
• Radiation –
• Aggravating Factor -
• Relieving Factor –
• Relation to menstruation-
• Associated with fever ?

3b) History of discharge from nipple
• U/L or B/L ?
• Duration –
• Nature – serous / bloody / milky
• Color –
• Odor –
• Quantity –


3c) history of Metastasis in Breast Ca

• History of bone pain (50-60%) - Long bones (femur) or Lumbar vertebrae (through Batson
plexus - valve less) , h/o back pain

HISTORY & EXAMINATION FOR BREAST CASE| Dr. Ankit Chandra

 • History of Jaundice – when 80% of liver is damaged
• Abdomen pain – stretching of Glisson's capsule
• Lung (20%) - Breathlessness , cough with hemoptysis
• Brain – headache , vomiting , seizure, blurring of vision , weakness of limbs
• Local spread – ulceration , swelling axilla
• Others – Pleura , soft tissue , adrenals


4. Past History
• H/O DM/ HTN / CAD _____ for how many years ? On which medications ?
• H/o asthma / TB/ epilepsy
• Any past history of similar swelling in the same or opposite side.
• Previous history of breast abscess
• History of any irradiation of the chest/neck ?



5. Personal History
• History of smoking – how many years? How many cigarette/bidis per day ?
• History of alcoholism /smoking ?
• Diet – High fat diet ?
• Any allergy to any drugs ?
• Drug intake – HRT

6. Menstrual & Marital History
• Age of menarche – *early menarche ?
• Marital status -
• Age at 1st child birth - *Late child birth ? *null parity ?
• Breastfeeding history ?
• Age of Menopause - *Late ?

HISTORY & EXAMINATION FOR BREAST CASE| Dr. Ankit Chandra


7. Family history
• Any Family history of breast /Ovarian ? *BRCA gene
• Uterine Tumour ?
• Detailed family history regarding similar illness or any history of gastrointestinal or
ovarian malignancy in 2–3 generations.


8. Summary of History

• ____ old postmenopausal lady presented with a lump in right breast for past ___months .
Lump is non painful , progressive in size , no h/o any skin changes over the lump . No
history of any predisposing factors for Breast Ca.
• Probably it a Malignant breast lump

Breast Examination
- Dr. Ankit Chandra


1) General Examination
• Comfortable at rest
• Conscious , co-operative
• Oriented to time , Place & Person
• Built (skeletal parameter) - moderate
• Nourishment (BMI based) - average/poor
• BMI = weight (kg) / ht in (mt)2

HISTORY & EXAMINATION FOR BREAST CASE| Dr. Ankit Chandra

 • Signs of Chemotherapy ?

• Pallor , icterus , cyanosis , clubbing , pedal odema , lymphadenopathy

Axillary Lymph node examination
Supraclavicular Lymph node Examination
Description of Lymphadenopathy
1. Location –
2. Size & Number – length X Breadth
3. Tender/Non-tender
4. Matting / Non -matted
5. Mobile / fixed
6. Consistency – hard (carcinoma)/ firm, rubbery nodes (lymphoma) / soft (infections or
inflammatory conditions) / fluctuant (Suppurant nodes)

2. Vitals – BP , Pulse , RR , temp , SPO2

3. Other system examination

Cardio-vascular System (CVS)

• Heart Rate & Rhythm-
• Heart sounds- S1 & S2
• Additional sounds – murmur, rub, gallop

Respiratory system (RS)
• Normal Breath sounds-
• Additional sounds
• Clear to percussion

HISTORY & EXAMINATION FOR BREAST CASE| Dr. Ankit Chandra

Abdominal-Pelvis Examination
• Any Mass in abdomen ?
• Free fluid ?
• Any organo-megaly ?
• Pelvic mass ?

4) Local examination
4a) Inspection –

A) Arms by the side of Body , patient sitting
• Breast – Size , Shape , symmetry , position ,any Lump seen ?
• Skin over the breast – dilated vein , Dimple /puckering / retraction , Peau d’orange ,
nodules , ulceration , fungation
• Nipple – B/L levels , retraction? deviation wrt mid line , position , number , size , shape ,
Discharge , ulcer
• Areola – Colour , size , surface , cracks /fissure/eczema? Discharge ?
• Arms & thorax – Edema of arms (lymphatic block by LN of axilla) , nodules
• Axilla – nodes ? Fullness ?
• Supraclavicular fullness ?

Lump in inspection
• Position / Quadrant
• Extent
• Size & shape
• Surface & margin
• Skin over the swelling

B) Inspection on Arms Raised above head
• Fullness in axilla ?
• Look at Infra-mammary space
• Retraction of nipple

HISTORY & EXAMINATION FOR BREAST CASE| Dr. Ankit Chandra

 • Peau d’orange

C) Inspection on Leaning forward
*only if lump is visible in sitting position
• To look for fixity of mass to chest wall

D) Inspection on contracting & relaxing Pectoralis major
• Look whether lump/swelling become prominent or not
• Dimpling becomes more obvious ?

E ) Inspection in Supine position


4b) Breast Palpation
• Local Warmth ?
• Palpation of glandular area, axillary tail
• Palpation of areolar area
• Palpation of nipple

If ulcer is present (Palpation)
• Site
• Size & shape
• Margin
• Floor
• Any discharge
• Surrounding area
• Tenderness
• Base of ulcer
• Mobility

HISTORY & EXAMINATION FOR BREAST CASE| Dr. Ankit Chandra

Swelling/Lump Palpation
• Local Warmth & Tenderness
• Number
• Site (Quadrant)
• Size
• Shape – globular(fibroadenoma) / uneven(Carcinoma)
• Margin – ill-defined /well defined/regular/irregular
• Consistency - soft (tumour necrosis) /Firm/Hard (Ca.) /variable
• Surface – Globular /irregular / Bosselated/ Smooth/Uneven
*Fluctuation & transillumination – for cystic swelling only

Plane & mobility of the lump
a) Fixity to skin – skin above the swelling can be pinched ?
b) Intrinsic mobility –
c) Fixity to breast tissue-
d) Fixity to pectoralis major -
e) Fixity to serratus anterior-
f) Fixity to chest wall-



Nipple Examination – Tumour? Discharge on palpation?

Other Examinations for metastasis
• Bony tenderness at spine , long bones, Skull
• Pelvis
• PR/PV – Metastatic deposit in Pouch of Douglas

HISTORY & EXAMINATION FOR BREAST CASE| Dr. Ankit Chandra

4C) Percussion over the sternum & 2nd ,3rd Intercostal space
Dull / resonant?

Don’t forget to examine & mention the opposite/normal breast, axilla & supraclavicular fossa of
the patient

6) Diagnosis
1. Right/left sided / Bilateral
2. TNM Staging of Breast Ca.
3. Staging – I /II /III/IV
4. Diagram

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HISTORY & EXAMINATION FOR BREAST CASE| Dr. Ankit Chandra