11/13/24, 8\:08 PM Guide | Breast lump history

Breast lump history

Table of contents

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you're running through a checklist in your head doesn't mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
“ W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?”
“ T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
“ O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?”
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
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Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

SOCRATES

The SOCRATES acronym (explained below) is a useful tool that you can use to further explore the characteristics of the patient’s
breast lump.
Site
Ask about the location of the breast lump\:
“ W h e r e i s t h e b r e a s t l u m p ?”
“ C a n y o u p o i n t t o w h e r e t h e b r e a s t l u m p i s ?”
Onset
Clarify when the breast lump developed\:
" W h e n d i d y o u
" H o w l o n g h a v e y o u b e e n a w a r e o f t h e b r e a s t l u m p ?
Character
Ask about the speci
" D o e s t h e b r e a s t l u m p f e e l s o f t o r h a r d ?"
" D o e s t h e b r e a s t l u m p f e e l s m o o t h o r i r r e gu l a r ?"
" I s t h e b r e a s t l u m p p a i n f u l ?"
Radiation
If pain is associated with the breast lump, ask if this radiates\:
" D o e s t h e p a i n f r o m t h e l u m p m o v e a n y w h e r e e l s e ?"
Associated symptoms
Ask if there are other symptoms which are associated with the breast lump\:
“ A r e t h e r e a n y o t h e r s y m p t o m s t h a t s e e m a s s o c i a t e d w i t h t h e b r e a s t l u m p ?”
See the key symptoms section below for examples.
Time course
Clarify how the breast lump has changed over time\:
" H a s t h e b r e a s t l u m p c h a n g e d i n s i z e o r t h e w a y i t f e e l s o v e r t i m e ?"
" O v e r w h a t t i m e p e r i o d h a s t h e c h a n ge o c c u r r e d ?"
" I s t h e l u m p' s s i z e o r d i s c o m f o r t r e l a t e d t o t h e m e n s t r u a l c y c l e i n a n y w a y ?"
Exacerbating or relieving factors
Ask if anything appears to have triggered the onset of a breast lump\:
" D i d t h e b r e a s t l u m p d e v e l o p a f t e r a s p e c i
If breast lump pain is present, ask if anything makes it worse or better\:
“ D o e s a n y t h i n g s e e m t o t r i g g e r t h e p a i n ?"
" D o e s a n y t h i n g i m p r o v e t h e p a i n ?"
Severity
Assess the severity of any associated pain by asking the patient to grade it on a scale of 0-10\:
“ O n a s c a l e o f 0-1 0 , h o w s e v e r e i s t h e p a i n , i f 0 i s n o p a i n a n d 1 0 i s t h e w o r s t p a i n y o u’ v e e v e r e x p e r i e n c e d ?”
Key symptoms
Key symptoms to ask about when taking a breast lump history include\:
https\://app.geekymedics.com/osce-guides/history/breast-lump-history/ 2/611/13/24, 8\:08 PM Guide | Breast lump history
Nipple discharge or bleeding\: associated with infection (e.g. mastitis and breast cancer).
Nipple inversion\: recent onset nipple inversion is typically associated with breast cancer.
Erythema\: associated with breast abscess, mastitis and underlying breast cancer.
Ulceration\: typically associated with breast cancer.
Dimpling (peau d'orange)\: associated with underlying breast cancer.
Fever\: may indicate underlying infection (e.g. breast abscess).
Weight loss\: may indicate underlying breast cancer.
Malaise\: associated with breast abscess and breast cancer.
Lymphadenopathy\: typically involving the lymph nodes of the axilla and neck (e.g. breast cancer, breast abscess).
Bone pain\: consider the possibility of metastatic breast cancer.

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient’s ideas about the current issue\:
“ W h a t d o y o u t h i n k t h e p r o b l e m i s ?”
“ W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g ?”
“ I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u gh t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
”
Concerns
Explore the patient’s current concerns\:
“ I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?”
“ W h a t’ s y o u r n u m b e r o n e c o n c e r n r e g a r d i n g t h i s p r o b l e m a t t h e m o m e n t ?”
“ W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i g h t b e ?”
Expectations
Ask what the patient hopes to gain from the consultation\:
“ W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?”
“ W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?”
“ W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?”

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
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, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
”
“ O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u’ r e h o p i n g w e
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What you plan to cover next\:
c u r r e n t l y t a k e .
”
“ N e x t I’ d l i k e t o d i s c u s s y o u r p a s t m e d i c a l h i s t o r y a n d t h e n e x p l o r e w h a t m e d i c a t i o n s y o u

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include\:
Systemic\: fevers (e.g. breast abscess)
Respiratory\: shortness of breath (e.g. lung metastases)
Gastrointestinal\: abdominal pain, nausea and vomiting (e.g. bowel obstruction)
Neurological\: confusion (e.g. brain metastases)
Musculoskeletal\: back pain (e.g. spinal metastases)

Past medical history

Ask if the patient has any medical conditions\:
" D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?"
" A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e g u l a r l y ?"
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
Ask if the patient has previously undergone any surgery or procedures (e.g. breast lump biopsy)\:
" H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?"
" W h e n w a s t h e o p e r a t i o n / p r o c e d u r e a n d w h y w a s i t p e r f o r m e d ?"
Take a focused obstetric and gynaecology history to identify risk factors for breast cancer such as\:
Early menarche
Late menopause
Treatment with continuous combined hormone replacement therapy
Not having breastfed
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs
Examples of relevant medical conditions
Medical history relevant to breast lumps includes\:
Previous breast lumps (including investigation results and management)
History of breast cancer
Continuous combined hormonal replacement therapy
Radiation to the chest (e.g. multiple scans or X-rays in the past)
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Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form
and route.
Ask the patient if they're currently experiencing any side e
" H a v e y o u n o t i c e d a n y s i d e e
Medication examples
Medications which increase the risk of breast cancer include\:
Combined oral contraceptive pill
Continuous combined hormonal replacement therapy

Family history

Ask the patient if there is any family history of breast, bowel or ovarian cancer\:
" I s t h e r e a n y h i s t o r y o f b r e a s t , b o w e l o r o v a r i a n c a n c e r i n y o u r c l o s e r e l a t i v e s ?"
Clarify at what age these diseases developed\:
" A t w h a t a g e d i d y o u r m o t h e r d e v e l o p b r e a s t c a n c e r ?"
Family history of breast cancer in a
mutations are implicated, with BRCA1, BRCA2 and TP53 mutations associated with the highest risk.

Explore the patient's social history to both understand their social context and identify potential breast cancer risk factors.
General social context
Explore the patient's general social context including\:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
if they have any carer input (e.g. twice daily carer visits)
Smoking
Record the patient's smoking history, including the type and amount of tobacco used.
Calculate the number of 'pack-years' the patient has smoked for\:
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
Smoking is a signi
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Alcohol is a signi
Recreational drug use
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Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Intravenous drug use is associated with an increased risk of developing abscesses.
Occupation
Ask about the patient's current occupation and assess the impact of their symptoms on their ability to work.

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Source\: geekymedics.com
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