OnExam

Identifying Information

Gather the patient's general identifying data.

Chief Complaint

Elicit the patient's chief complaint.

History of Presenting Illness (HPI)

Characterize each of the patient's principal symptoms using the OPQRST/OLD CARTS approach.

Breast lump

Ask about:

  • Specific location
  • Date first noticed and changes since first noticed
  • Changes with menstrual cycle
  • Swelling
  • Redness
  • Warmth
  • Dimpling
  • Trauma

Breast pain

Ask about:

  • Localized or diffuse
  • Unilateral or bilateral
  • Intermittent or constant
  • Sore to touch
  • Changes with menstrual cycle
  • Aggravating and alleviating factors (specific cause such as exercise or particular bra)

Nipple discharge

Ask about:

  • Date of first notice
  • Disappearance: spontaneous vs. with nipple compression
  • Changes with menstrual cycle
  • Recent trauma or injury
  • Unilateral or bilateral
  • Colour
  • Blood
  • Volume
  • Consistency
  • Odour

Rash

Ask about:

  • Date first noticed
  • Specific location; nipple, areola, breast (use clockface in reference to nipple, i.e. one o'clock), etc.
  • Pattern of spread

Swelling

Ask about:

  • Localized or diffuse
  • Occurrence with menstruation, pregnancy, or breastfeeding
  • Changes in bra size

Risk Factors for Breast Cancer

Note the following associations and their strength:

Relative Risk (RR) > 4.0

  • Female
  • Age 65+
  • BRCA1/BRCA2 mutation
    • BRCA1 mutations: 57% risk by age 70
    • BRCA2 mutations: 49% risk by age 70
  • >1 first-degree relative with breast cancer (the younger the relative at diagnosis, the higher the risk for the patient)
  • History of breast cancer
  • History of atypical hyperplasia (biopsy-confirmed)

Relative Risk (RR) = 2.1 - 4.0

  • One first-degree relative with breast cancer
  • History of chest radiation (high-dose)
  • High postmenopausal bone density

Relative Risk (RR) = 1.1 - 2.0

  • First full-term pregnancy at age 30+
  • Nulliparity (non-childbearing)
  • Never breastfed
  • Early menarche (age < 12)
  • Late menopause (age > 55)
  • Hormone replacement therapy (HRT of estrogen + progestin) within the last five years
    • Estrogen-only HRT for women without uterus is not a risk factor
  • Postmenopausal obesity
  • History of endometrium, ovarian, or colon cancer
  • Alcohol consumption
  • Tall stature
  • High socioeconomic status
  • Ashkenazi Jewish heritage
  • African-American heritage (earlier occurrence and larger tumours = 36% higher death rate from breast cancer)
  • Increased breast density (greater risk and less sensitivity and specificity of mammograms)
  • Oral contraceptive use within last 10 years

Past History (PHx)

Specifically ask about:

  • Breast surgeries
    • Biopsy
    • Lumpectomy
    • Mastectomy
    • Mammoplasty
  • Previous clinical breast examination findings
    • (note: CTFPHC recommends not routinely performing CBE with low-risk women as a screening tool)
  • Previous breast self-examination findings
    • (note: CTFPHC recommends not advising low-risk women to routinely perform BSE as a screening tool)
  • Mammography (negative mammogram does not rule out breast cancer)
  • BRCA1 and BRCA2 screening

Family History (FmHx)

Specifically ask about:

  • Cancers, especially breast, ovarian, and colon

Social History (SocHx)

Specifically ask about:

  • High-fat diet
  • Occupation
  • Work and home environments
  • Diet and exercise

Substance Use

Specifically ask about:

Medications

Gather complete list, but specifically ask about:

  • Oral contraceptive pills
  • Hormone replacement therapy

Allergies

Note allergies and ensure they concord with those listed in the EMR

Immunizations

Note immunizations and ensure they are up to date in the patient's record.

Review of Systems

Conduct a review of systems, keeping other etiologies from your differential in mind.

References

  1. American Cancer Society. Breast Cancer Facts and Figures 2009-2010. Atlanta: American Cancer Society, Inc; 2010.
  2. Barton M, Harris R, Fletcher S. The rational clinical examination: Does this patient have breast cancer? JAMA. 1999;282(13):1270-1280.
  3. Bickley LS. Bates' Guide to Physical Examination and History Taking. 11th Ed. Philadelphia: Lippincott, Williams & Wilkins; 2013.
  4. Canadian Task Force on Preventive Health Care (2011). Recommendations on screening for breast cancer in average-risk women aged 40–74 years. Canadian Medical Association Journal, 183(17), 1991-2001.
  5. Jarvis C. Physical Examination & Health Assessment. Toronto (ON): Elsevier; 2009.
  6. Lincoln M, McSheffrey G, Tran C, Wong D. Essentials of Clinical Examination Handbook. 6th Ed. Toronto: University of Toronto Medical Society; 2010.