Medically Fit For Exams
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Breast history taking

​The presenting complaint is likely to be pain, lump or discharge. For the sake of this guide, will will use a lump as an example, but consultation should cover all three anyway.

 

  • Wash your hands and introduce yourself
  • Check the patient’s name and DOB
  • Ask if it’s okay to have a chat before the patient sees the doctor

 

History of presenting complaint

  • ‘What has brought you in today?’
  • ‘Tell me more about the lump’
  • ‘How long have you had the lump?’

Site

Onset

Character

Radiation

Associated symptoms

Time-course

Exacerbating/relieving factors

Severity

  • Did it come on suddenly, or gradually?
  • Did anything precipitate it?
  • When/how did you notice it?
  • Is it painful?
    • If yes, follow SOCRATES pain mnemonic
  • Is it associated with your period (if appropriate)?
  • Do they have any associated symptoms?
    • Nipple discharge
    • Nipple inversion
    • Skin changes
  • Ask if the patient has had these symptoms before
  • Ask about cancer red flags
    • Weight loss
    • New onset fatigue
    • Pain anywhere else, eg back pain or abdomen
    • Enlarged lymph nodes
  • Summarise

Age for mammogram screening

50 - 70

47 – 73 in some areas

 

Past medical history

  • Ask when the patient last had a mammogram, if relevant
  • Does the patient still have periods?
  • At what age was the menopause?
  • What age did they start their periods?
  • How many times have they been pregnant?
    • How many children they have
  • Did they breastfeed?
    • How long for?
  • Have they ever taken the contraceptive pill or had hormonal treatment?
    • How long for?
    • Over the age of 35?
  • Have they had any breast problems/cancer before?
  • Do they have any medical problems?
    • Have they ever had cancer?
  • Recent breast trauma?
  • Previous surgery?

 

Family history

  • Have any members of the patient’s family had breast cancer?
    • If yes, who? And at what ages? Was their cancer treated?
  • Have any members of their close family had any other kind of cancer?
    • Who? What type? What age? Cured?

 

Drug history

  • Are they taking any regular medication?
  • Anything over the counter?
  • Any supplements?

 

Allergies

  • Do they have any allergies?
    • If yes, to what? What happens?

 

Social history

  • Smoker?
  • Alcohol?
  • Occupation?
  • With whom/where they live (especially for older patients)

 

Summary

  • Ask if the patient has any questions or anything they’re concerned about
  • Ask if there’s anything else that you haven’t asked
  • Summarise again if necessary
  • Thank the patient for talking to you

 

Next steps

  • Examination
  • Referral to triple-stop breast clinic
    • Examination
    • Imaging (ultrasound if <40, mammogram if >40)
    • Biopsy if necessary
Breast history taking.docx
Microsoft Word document [19.1 KB]

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