Breast Diseases
(History)
How you take a history from a patient present with a breast complaint?
The patient with breast diseases will present with one or more of the following complaints:
1- Breast mass.
2- Nipple discharge.
3- Breast pain (mastalgia).
How to take the history?
1-Personal data: Name, age, sex, nationality, from where the patient is admitted and for
how long she is in the hospital.
e.g.: A 30 years old Saudi female patient admitted yesterday from the emergency
department C\O
2- The chief complaint with the duration:
e.g.:
C\O left breast mass for 5 days duration
3- History of the present illness:
For the mass: how the patient discovers it, for how long, any change in the size, any
associated symptoms as fever, pain, nipple discharge, weight loss…any other lump in the
same breast or the other breast or in the axilla or the neck.
e.g.: the patient was completely well till 5 days ago when she started to feel a mass in the
left breast, it was small, but increasing in the size by time, associated with fever and pain, no
nipple discharge, she noticed another swelling in the left axilla…
For the nipple discharge:
Ask for the duration, the color (milk, yellow (serous), or bloody), any associated symptoms
as mass, pain, is there discharge from the other nipple.
For the pain:
Ask if it is cyclic or non cyclic i.e. any association between the pain and the menstrual cycle,
and ask all the questions of the pain ( site, duration, onset character, aggravating and
reliving factors, radiation, associated symptoms as nipple discharge, mass, fever, weight
loss…)
Then you have to ask about the risk factors for cancer breast as:
Is the patient married, for how long, is she has children, lactating or not, history of oral
contraception use or hormonal replacement therapy, the age of first child bearing, family
history of breast cancer, previous history of benign or malignant breast disease.
e.g.: the patient is married for 2 years and has one child, she became pregnant at the age of
28 years, lactating now, no history of oral contraceptive or hormonal replacement therapy,
no previous history of benign or malignant breast disease, no family history of breast cancer.
Systemic review:
Don’t forget to ask about the symptoms of metastasis as skeletal system ( bone pain),
respiratory system, cough, hemoptesis, chest pain, sputum, CNS ( headache, convulsion,
weakness)…
- Past medical and surgical history.
- Family history.
- Social history.
- History of Drug and allergy.
- Summary of the history.
To see e.g. refer to the history in thyroid disease.
DR. S. ALDAQAL