Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a junior doctor on your GP rotation. Your next patient is 77-year-old Margaret Robson, presenting with a breast problem. Please take a history and perform a relevant examination.
Patient History:
77-year-old Margaret Robson - retired.
You've had a lump in your left breast for some time, though you never thought much of it since you've had breast cysts in the past, most of which went away (though one of them required drainage), and this looks like it might just be another one that needs draining.
The lump is in the upper outer edge of your left breast. It is not painful and has been gradually growing over the past 3 months, unrelated to menses since you had menopause ages ago. It feels somewhat rock-bound. When asked specifically, your previous cysts didn't feel like this.
You have no nipple discharge or bleeding. You have noticed your nipple has somewhat flattened on the left side. You have noticed no skin changes like dimpling or orange discolouration. You recall no trauma to your breasts.
No fever, back pain or weight loss.
Ideas, Concerns, Expectations:
You think this is another one of those cysts, hence why you didn't think much of it until later when you thought it needed to get drained. You're not overly concerned – the drainage process last time barely hurt.
Gynaecological History:
You had your first period at 11 years and the menopause at 55. Your periods were normally regular, with no bleeding/pain problems. You used combined HRT for 10 years after menopause. Normal smears. You are not currently sexually active since your husband died 10 years ago.
Obstetric History:
You had one daughter when you were 35 (yes, she was very late!) who was born at 39 weeks by Caesarean section since she was breech. No other complications. She was bottle-fed.
Past Medical History:
Osteoarthritis. Hypertension. Type 2 diabetes mellitus.
Drug History:
Ibuprofen 400mg PRN │ clopidogrel 75mg │ atorvastatin 80mg │ ramipril 2.5mg OD │ metformin 500mg TDS.
No known drug allergies.
Family History:
Your mother had breast cancer when she was 65 but was treated successfully. Your first-degree cousin had a history of "breast mice".
Social History:
You live at home with your cat, Horace. You don't smoke since you stopped 20 years ago, before which you smoked 20/d for 40 years. You enjoy the occasional glass of red wine but nothing excessive. You're now retired but previously worked as a receptionist at the local hospital where you saw all manner of people coming through the door!
Examination Findings:
Palpable 3x4cm lump in the upper outer quadrant of the left breast. 7cm away from the nipple at 1 o'clock. Feels firm to touch, with poorly defined edges, not tethered to overlying skin. When asked to contract chest muscles, the lump becomes less mobile. When arms are raised behind the head, you note some skin dimpling over the lump.
Nipple inversion (left).
One lymph node is palpable in the left axilla. None cervical.
Right breast and axilla normal.
Differentials:
Breast cancer
Benign cystic changes (aka fibrocystic disease)
Non-breast lumps e.g. lipoma, sebaceous cyst.
Abscess
Fat necrosis
Investigations:
Two-week wait referral for specialist input for suspected breast cancer.
Triple assessment:
History & Clinical Examination
Imaging = mammogram ±USS
Fine-needle aspiration or core biopsy
If diagnosing cancer, further investigations:
Routine Bloods e.g. LFT (liver mets), bone profile (serum calcium & phosphate) + FBC
Other imaging e.g. CXR, MRI, CT TAP, isotope bone scan to look for spread.
Management of breast cancer depends on the type, staging and functional status of the patient: