Breast Lump - History Taking

Being able to take a breast lump history is an important skill that is often assessed in the OSCE setting. It’s important to have a systematic approach to ensure you don’t miss any key information. The guide below provides a framework to take a thorough breast lump history. Check out the breast lump history mark scheme here.
Opening the consultation

• Introduce yourself – name / role
• Confirm patient details – name / DOB
• Explain the need to take a history
• Gain consent
• Ensure the patient is comfortable

Presenting complaint

• It’s important to use open questioning to elicit the patient’s presenting complaint

“So what’s brought you in today?” or “Tell me about your symptoms”

• Allow the patient time to answer, trying not to interrupt or direct the conversation.

• Facilitate the patient to expand on their presenting complaint if required.

“Ok, so tell me more about that” “Can you explain what that pain was like?”

History of presenting complaint
Questions to ask about the lump
- Size – Has it changed? / Over what duration?
- Onset – When did they first notice the lump?
- Is the lump painful? – ask SOCRATES (shown below)
- Is the lump’s size or discomfort related to the menstrual cycle in any way?
- Pain – if pain is a symptom, clarify the details of the pain using SOCRATES

• Site – where is the pain
• Onset – duration? / sudden vs gradual?
• Character – sharp / dull ache / burning
• Radiation – does the pain move anywhere else?
• Associations – other symptoms associated with the pain (e.g. fever)
• Time course – worsening / improving / fluctuating
• Exacerbating / Relieving factors – anything make the pain worse or better?
• Severity – on a scale of 0-10 how severe is the pain?

Local associated symptoms
- Nipple discharge or bleeding?
- Nipple inversion? – Is this new or has it always been the case?
- Skin changes overlying the lump or elsewhere on the breast?

• Eczema
• Dimpling
• Ulceration

Systemic symptoms

• Weight loss
• Fever
• Lethargy
• Pain elsewhere – e.g. spine / axilla / abdomen
• Gland swelling – lymphadenopathy

Other questions
Has the patient ever experienced similar symptoms in the past?
If any of the above symptoms are present, gain further details

• Onset – When did the symptom start? / Was the onset acute or gradual?
• Duration – Days / Weeks / Months / Years
• Severity – i.e. How much is the given symptom impacting on their life?
• Course – Is the symptom worsening, improving, or continuing to fluctuate?
• Intermittent or continuous? – Is the symptom always present or does it come and go?
• Precipitating factors – Are there any obvious triggers for the symptom?
• Relieving factors – Does anything appear to improve the symptoms?
• Previous episodes – Has the patient experienced this symptoms previously?

Ideas, Concerns and Expectations

• Ideas – what are the patient’s thoughts regarding their symptoms?
• Concerns – explore any worries the patient may have regarding their symptoms
• Expectations – gain an understanding of what the patient is hoping to achieve from the consultation

Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you.
It also allows the patient to correct any inaccurate information and expand further on certain aspects.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
Continue to periodically summarise as you move through the rest of the history.

Signposting
Signposting involves explaining to the patient:

• What you have covered – “Ok, so we’ve talked about your breast lump and your concerns regarding it”
• What you plan to cover next – “Now I’d like to discuss your past medical history and your medications”

Past medical history
Relevant gynaecological history:

• Age at menarche / menopause
• Parity
• Age at first pregnancy
• Did they breast feed?
• Use of hormonal replacement therapy or oral contraceptive pill

Relevant past medical history:

• Recent breast trauma – fat necrosis
• Previous breast disease – malignant or benign?
• Any other previous malignancies?
• Other significant medical problems?

Surgical history – breast surgery / other surgery

Drug history
- Relevant prescribed medication:

• Oral contraceptive pill
• Hormonal replacement therapy

- Other regular medications.
- Over the counter drugs.
- herbal remedies.
- ALLERGIES – ensure to document these clearly

Family history
Family history of breast disease – consider BRCA mutations

Social history
- Smoking – How many cigarettes a day? How many years have they smoked for?
- Alcohol – How many units a week? – type / volume / strength of alcohol
- Recreational drug use?
- Living situation:

• Do they have accommodation?
• Who lives with the patient? – is the patient supported at home?
• Any carer input? – what level of care do they receive?

- Activities of daily living:

• Is the patient independent and able to fully care for themselves?
• Is the symptom impacting on their abilities to carry out daily activities?

- Occupation – Is the patient currently coping at work? What are their expected duties?

Systemic enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body systems.
This may pick up on symptoms the patient failed to mention in the presenting complaint.
Some of these symptoms may be relevant to the diagnosis (e.g. reduced urine output in dehydration).
Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.

• Cardiovascular – chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema
• Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / chest pain
• GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit
• CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion
• Musculoskeletal – Bone and joint pain / Muscular pain
• Dermatology – Rashes / Skin breaks / Ulcers / Lesions

Closing the consultation

• Thank patient
• Summarise history

Source