Name:
Age/Sex:
Occupation:
Socioeconomic Status:
Presenting Complaints
• Lump in the right/left breast for last………….. months/years.
Also Read:
History of Presenting Illness
H/O Lump
Site
Duration
Onset
Progress of the swelling:
Associated
H/O Pain
Site
Duration
Onset
Character: Usually dull-aching
Radiation
Relieving factors
Aggravating factors
H/O Ulcer
Site
Duration
Onset
Progress of the ulcer
Associated
H/O Nipple Discharge
Duration
Type: Bloody/ Not Bloody
Color of Discharge
H/O Nipple retraction
R/O Axilla Involvement
H/O Swelling in axilla and neck—details of the swelling
R/O Trauma
H/O Trauma
R/O Infection
H/O Fever
R/O Metastasis
H/O Chest pain/ Cough/ Hemoptysis
H/O Loss of Appetite/ Weight loss
H/O Pain in abdomen
H/O Jaundice
H/O Low backache
H/O Headache/ Loss of consciousness/ Vomiting/ Weakness of any of the limbs
Past H/O
H/O Similar illness in past
H/O Previous Surgeries
H/O DM/HTN/IHD/TB/COPD/BA/Epilepsy
Personal H/O
H/O Smoking
Duration
No of Cigarettes/ Bidis per day
H/O Tobacco chewing
H/O Alcoholism
Menstrual and Marital H/O
Age at Menarche
Age at first child birth
Marital Status
Breastfeeding
Age at Menopause
LMP
Regular Cycle, Moderate Flow (3/30)
Family H/O
H/O Similar illness (Breast Ca/ Ovarian Ca/ Uterine Ca)
Treatment H/O
H/O Any Ongoing Medications (Antithyroid/Eltroxin/Propanolol)
H/O Previous Hormone Replacement Therapy
Allergic H/O
H/S/O Allergy to specific medications
Summarize the History
General Examination
Conscious/ Oriented/ Cooperative
Moderately built and nourished
ECOG
0-asymptomatic
1-restricted strenuous activity,
2-ambulant capable of self-care but no work activities
3-Capable of only limited Self-care
4-bed ridden
Pallor/ Ictus/Cyanosis/Clubbing/ Pedal Edema/ Generalized Lymphadenopathy
B.P-130/80
PR-90/ Min (Rate, Rhythm, Volume, Character (collapsing or not), Delay- Radioradial, Radiofemoral)
Regional Examination
Inspection
1. Arms by the side and patient sitting
Breast
Size and shape of breast in comparison to opposite breast
Position compared to normal breast
Any Lump
Ulcer
Nipple
Position in comparison to opposite side
Cracks
Fissure
Ulcer
Discharge
Areola
Size
Cracks
Fissure
Ulcer
Eczema
Discharge
Arms and thorax
Nodules
Edema
Cancer en cuirasse: Thickened skin like an Armor in arms and thorax with Multiple cancerous nodules
Axilla: Look for visible ulcerated or inflamed Nodes
Supraclavicular fossa: Look for fullness
2. Inspection with arms raised above head
Observe for following
Peau d’orange
Fixity
Retraction of nipple
3. Patient leaning forward
Check for fixity to the chest wall
If fixed to the chest wall, the breast will not fall forward on leaning compared to the opposite side
4. Hands over hips - with alternative contraction and release of pectoralis muscle
Check if swelling becomes prominent with contraction of muscle
Palpation
Palpate starting from the nipple, then areola and then concentrically outward
1. Local temperature
2. Tenderness
3. Swelling Description: Site, Number, Size, Shape, Margin, Consistency, Fluctuation (Present in Cystic swellings only)
4. Plain of the swelling
a. Check for - Fixity to skin
b. Check for - Intrinsic mobility
c. Check for - Fixity to muscles
d. Check for - Fixity to chest wall
5. Any Ulcer
Site
Size
Shape
Edges
Floor
Base
Margins
Discharge
Tenderness
Mobility
6. Palpation of Axillary Lymph Nodes
Level 1- Lymph nodes which are lateral to the lateral border of pectoralis minor muscle
Anterior (Pectoral)
Posterior (Subscapular)
Lateral (Brachial)
Level 2- Lymph nodes which are posterior to pectoralis minor muscle
Central
Rotters
Level 3-Lymph nodes which are medial to medial border of pectoralis minor muscle
Apical (Infraclavicular)
Systemic Examination
CVS: S1 S2 Heard, No Murmurs
RS: Bilateral Air Entry +, Normal Vesicular BS, No Added Sounds
CNS: No neurological deficits
P/A: Soft, Not tender, BS+
Spine and Cranium
Summary of the Case
Provisional Diagnosis
Carcinoma of Rt/ Lt Breast„
TNM definition of tumor, e.g. T1N1M0/ T4bN2M0
Staging depending on T, N, M. Stage I/II/ III/IV
No Comorbidities
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