1.
Breast lump
Patient particulars
Name
Age
Gender
Address
Education
Occupation
Date of admission
Date of examination.
Chief complaints.
Lump in the the breast
History of present illness.
*H/oLump.
Onset
Duration
Progression.
Rate of growth
H/o trauma
Ulceration
Skin over the lump
Pain
-Onset
-Duration
-Progression
-Nature of pain
-Radiation
-Cyclical variation.
-Aggregating factor
-Releving factor.
*Discharge from the nipple
*Retraction of nipple
*Ulceration or any skin changes noticed
*Lump noticed any where else in the body
*Loss of weight.
Past history.
H/o similar complaints in the past.
H/o Of diabetes,hypertension,asthma,malignancy,Tuberculosis in the past.
H/o surgery and medical interventions.
H/o Drug allergy or allergy to food.
Menstrual history.
Age of attainment of menarche
Regualrity cycles, duration of cycle
How many days of flow
Usage of pads/tampons/cloths-how many /day
Associated dysmenorrhea,passage of clots
Marital history and obstetric history.
Married since how long
Consanginous/non-consanguinous marriage
What is husband's occupation.
Parity index.
Number of children
Gender
Age
Immunized till date.
Any antenatal/natal /postnatal complications.
Family history.
H/o similar complaints in the family
h/o diabetes,hypertension,asthma,malignancy,Tuberculosis in the past.
Personal history.
Vegetarian /non vegetarian
Appatite
Sleep
Bowel and bladder habits
Subactance abuse
H/o allergy to any drug ,food
Environmental history
Lives in pakka/kchcha house
How many rooms in the house.
Number of people in the house.
Vector breeding areas around house
Areas of water stagnation.
Adequate light and ventilation.
Cooking with LPG/fire wood
Water supply
Drinking water.
Sanitation
Waste disposal
Socioeconomic history
Head of the family
Number of people in the house
Total income of the family
Per capita income
Summary after history.
General physical examination:
Patient is conscious,cooperative,well oriented to Time place and person.
Built(Skeletal frame work and height)
Nourishment(muscle mass/BMI)
Vitals:
Pulse
Blood pressure
Respiration.
Temperature.
Pallor
Icterus,
Cyanosis
Clubbing
Edema
Lymphadenolathy
Head to toe examination.
Local examination .
Inspection. Right Left
Breasts
Position
Size and shape
Any puckering or dimpling.
Skin over the breast.
Colour
Texture
Engorged veins
Dimple ,retraction,puckering
Peau d' orange appearance.
Nodules
Ulceration and fungation.
Nipple
Presence
It's position
Number
Size and shape
Surface
Discharge
Areola
Colour
Size
Surface
Texture
Arm and thorax.
Look for Skin changes.
Browny edema
Cancer en crirasse
Axilla and supraclavicular area
Patient asked to raise her arms above her head.
Palpation.(right and left)
Local rise of temperature
Tenderness
Situation
Number
Size
Shape
Extent
Surface
Margin
Surrounding area
Consistency
Fluctuation
Transillumination
Fixity to the breast tissue
Fixity to the underlying fascia and muscles
Fixity to the chest wall
Palpation of the nipple.
Examination of ulcer if present
Examination of the lymph nodes.
Palpation of Axillary group of lymph nodes
Pectoral
Brachial
Subscalular
Central
Brachial
Apical
Palpation of cervical lymph nodes.
Systemic examination.
CNS
C
V
S
R
S
Abdo
men
Sum
mary.
Provisional
diagnosis
Differential
diagnosis
Investigation
Treatment.
Follow up.
