Breast lump — model clerking

Patient details

Name: Mrs H.M.
Age / sex: 48-year-old woman
Occupation: Schoolteacher
Marital status: Married, two children
Seen: Breast clinic, 09:30
Clerked: Breast clinic, 09:45
Source: Patient herself, reliable
Referred by: Family doctor

Presenting complaint

“A lump in my left breast for six weeks.”

History of presenting complaint

Mrs H.M. was well until six weeks ago, when she felt a lump in the upper outer part of her left breast while showering. It was then the size of a chickpea and is now the size of a walnut. It is painless and feels hard, and it does not change in size or tenderness with her periods. She has noticed no discharge from the nipple, no change in the shape or direction of the nipple, and no dimpling, redness or ulceration of the skin. She has not felt a lump in either armpit, and her right breast is normal. She has had no previous breast lumps, biopsies or breast operations, no injury to the breast, and no fever; she is not breastfeeding. She has no bone or back pain, no cough or breathlessness, no jaundice or abdominal swelling, no headache and no weight loss. Her periods began at the age of 11 and are still regular, the last one starting ten days ago. She had her first child at 31 and has two children, each breastfed for about three months. She took the oral contraceptive pill for eight years in the past and has never used hormone replacement. She has had no radiotherapy to the chest. Her mother was treated for breast cancer at 52 and a maternal aunt had ovarian cancer. She has never had a mammogram. She is frightened that this is the same disease her mother had.

One continuous storyA single passage in time order, with no sub-headings and no bullet points.

The lump firstWhen and how it was found, how it has changed, pain, and relation to the menstrual cycle. A lump that grows steadily and ignores the cycle is suspicious.

Then nipple, skin and armpitDischarge with its colour, nipple inversion that is new, dimpling, redness, and lumps in the axilla. Each is stated as present or absent.

Then symptoms of spreadBone, lung, liver and brain, in one sentence.

Then the risk factorsA long exposure to oestrogen raises the risk: early first period, late first child, little breastfeeding, late menopause, the pill and hormone replacement. They are written into the story, with the family history, because they are part of this complaint.

Her concernRecord what the patient fears, in a sentence. In the OSCE, asking about ideas, concerns and expectations carries its own marks.

Past medical history

No chronic illness.

Past surgical history

One caesarean section in 2012, with no complications.

Drugs and allergies

No regular medication. No known drug allergies.

Family history

Mother: breast cancer at 52, alive. Maternal aunt: ovarian cancer at 60. No male breast cancer in the family.

Social history

Does not smoke or drink alcohol. Lives with her husband and two children.

General examination

A well-looking woman, anxious but comfortable. Not pale, not jaundiced. Weight 68 kg, with no recent change.

Temperature36.7 °C

Pulse82 /min, regular

Blood pressure124/76 mmHg

Respiratory rate14 /min

Oxygen saturation99% on air

Breast examination

Examined with consent, in the presence of a female chaperone, undressed to the waist.

Inspection

Sitting with arms by her sides, then raised above the head, then with hands pressed on the hips. The breasts are of similar size. On raising the arms, dimpling of the skin appears over the upper outer quadrant of the left breast. Both nipples are at the same level and point outwards, with no discharge and no scaling. No redness, no orange-peel skin, no visible veins, no scars.

Palpation

Lying at 45 degrees with the hand behind the head. The right breast was examined first and is normal. In the left breast there is a single lump in the upper outer quadrant, at 2 o'clock, 5 cm from the nipple. It measures 3 by 2.5 cm, is hard, with an irregular surface and an ill-defined edge, and is not tender or warm. The skin over it dimples when the lump is moved, so it is tethered to the skin. It moves freely over the chest wall both with the pectoral muscle relaxed and with it tensed. No other lumps. No discharge when she presses the nipple herself.

Lymph nodes

Left axilla: two firm, mobile, non-tender nodes of about 1 cm in the central group. Right axilla: no nodes. No nodes in either supraclavicular fossa.

Consent and chaperone come first in writingThey are part of the record and protect patient and doctor.

Three positions for inspectionRaising the arms shows tethering of the skin. Pressing on the hips tenses the pectoral muscle and shows fixation to it.

Normal side firstIt shows you what is normal for her and gains her confidence.

Describe every lump the same waySite by quadrant and clock face with distance from the nipple, size in centimetres, shape, surface, edge, consistency, tenderness, temperature, then attachment to skin and to muscle.

Tethered or fixedTethering means the skin dimples but still moves over the lump. Fixation means it cannot move at all. Record which.

The examination is not finished without the nodesBoth axillae and both supraclavicular fossae. Describe number, size, consistency and mobility.

Other systems

Chest: clear, no pleural effusion.

Abdomen: liver not palpable, no ascites.

Spine: no tenderness on percussion.

Arms: no swelling.

Summary

Say this to the examinerMrs H.M. is a 48-year-old premenopausal woman whose mother had breast cancer, who presents with a painless, enlarging lump in the left breast for six weeks. On examination there is a 3 cm hard, irregular lump in the upper outer quadrant of the left breast, tethered to the skin and not fixed to the chest wall, with two mobile nodes in the left axilla and no clinical evidence of distant spread.

Provisional diagnosis

Carcinoma of the left breast, clinical stage T2 N1 M0.

Plan

Complete the triple assessment: clinical examination, imaging and tissue diagnosis.
Mammography of both breasts and ultrasound of the left breast and axilla.
Core needle biopsy of the lump, with hormone receptor and HER2 status. Sampling of an axillary node if abnormal on ultrasound.
Results to be given by the consultant, and the case discussed at the multidisciplinary meeting.
Referral for genetic counselling in view of the family history.

Differential diagnosis of a breast lump

Use the age of the patient and the character of the lump. Say which features are for and against in your patient.

Diagnosis	Points to it in the history	Points to it on examination	In this patient
Malignant
Carcinoma of the breast	Over 35, painless growing lump, family history, no change with periods	Hard, irregular, ill-defined, tethered to skin, axillary nodes	Most likely
Phyllodes tumour	Rapidly growing large lump, age 40 to 50	Large, smooth, mobile, lobulated; skin stretched and shiny	Lump is small and irregular
Benign lumps
Fibroadenoma	Age 15 to 30, slow growing, painless	Firm, smooth, well-defined, very mobile	Wrong age, wrong character
Breast cyst	Age 35 to 50, appears quickly, may be tender	Smooth, tense or fluctuant, well-defined	Hard and irregular
Fibrocystic change	Lumpiness and pain in both breasts that vary with the cycle	Ill-defined nodular areas, often both upper outer quadrants	No cyclical change
Fat necrosis	Injury or surgery to the breast, sometimes forgotten	Hard, irregular, may tether the skin; imitates cancer	No injury; biopsy decides
Breast abscess	Breastfeeding, pain, fever	Hot, red, tender, fluctuant	Not lactating, not tender
Duct ectasia and periductal mastitis	Smoker, around menopause, green or creamy discharge	Lump beneath the areola, slit-like nipple retraction	Lump is far from the nipple
Intraductal papilloma	Blood-stained discharge from a single duct	Small lump near the areola or none	No discharge
Galactocele	Recently stopped breastfeeding	Smooth, mobile, non-tender cyst	Not applicable
Lipoma	Slow growing for years	Soft, lobulated	Hard lump
Not from the breast
Sebaceous cyst	Lump in the skin with a punctum	Moves with the skin	Lump is in the breast
Costochondritis	Pain over the ribs, worse on movement	Tender rib junction, no breast lump	No pain

Model OSCE answer“I have completed the clinical part of the triple assessment. My diagnosis is carcinoma of the left breast, because she is 48 with a family history, and the lump is hard, irregular, ill-defined and tethered to the skin, with mobile axillary nodes. Clinically this is T2 N1 M0. My differentials are fat necrosis, which can imitate cancer exactly, a breast cyst and fibrocystic change, but none explains the nodes. I would complete the triple assessment with mammography and ultrasound and a core biopsy.”

Clinical signs related to this case

The signs you should look for in any patient with a breast lump. For each one, know how to elicit it and what a positive result means.

Sign	How to elicit it, or what you see	What it means
Signs in the skin
Skin dimpling	Appears or deepens when the arms are raised or the lump is moved	Tethering: the tumour is pulling on the ligaments of the breast
Orange-peel skin	Thickened skin with pitting at the hair follicles	Skin lymphatics are blocked by tumour: locally advanced cancer
Redness and warmth of the whole breast	Swollen, red, warm breast without fever, not breastfeeding	Inflammatory breast cancer, often mistaken for infection
Ulceration or skin nodules	Tumour breaking through the skin, or small nodules around it	Locally advanced cancer
Signs at the nipple
Recent nipple retraction	Nipple pulled in or changed direction over weeks or months	Cancer beneath the nipple. A slit-like retraction for years suggests duct ectasia.
Blood-stained discharge from one duct	Ask the patient to express it herself; note the colour and whether one duct or several	Intraductal papilloma or cancer
Eczema of the nipple (Paget's disease)	Red, scaly, crusted nipple on one side that destroys the nipple	Underlying breast cancer. Ordinary eczema affects the areola, both sides, and spares the nipple.
Signs of the lump
Fixation to the pectoral muscle	Mobility of the lump is lost when she presses her hands on her hips	Tumour has invaded the muscle
Fixation to the chest wall	Lump cannot be moved even with the muscle relaxed	Tumour has invaded the chest wall: T4
Very mobile lump	Firm smooth lump that slips away from the fingers	Fibroadenoma, the “breast mouse”
Fluctuation	Smooth, tense lump that transmits pressure between two fingers	Cyst
Signs of spread
Axillary nodes	Hard nodes; mobile, or matted together and fixed	Mobile: N1. Fixed or matted: N2.
Supraclavicular node	Hard node above the clavicle on the same side	N3 disease
Swelling of the arm	Whole arm swollen on the affected side	Axillary lymphatics blocked by tumour, or previous axillary surgery
Tender spine, hard liver, pleural effusion	Percuss the spine, palpate the liver, percuss the lung bases	Distant spread

Key: three positions, four quadrants, two axillaeSay this to yourself before every breast examination. Do not forget the tail of the breast running into the axilla.

Key: tethering and fixationTethering to skin is a sign of cancer but does not change the T stage. Fixation to the chest wall or involvement of the skin itself makes it T4.

Do not be reassured by pain or by ageMost cancers are painless, but a painful lump can still be cancer, and so can a lump in a young woman. Every discrete lump gets triple assessment.

Red breast that is not infectionA red, swollen breast in a woman who is not breastfeeding and does not improve on antibiotics is inflammatory cancer until a biopsy proves otherwise.

Key: in this patientDimpling on raising the arms, a hard irregular lump tethered to skin, free of the muscle, with mobile axillary nodes and nothing above the clavicle. That is T2 N1.

Teaching case. The patient is fictional and written to illustrate format and reasoning. Local protocols decide investigation and treatment.