• Mass - br, axilla (both sides)
• Pain
• Discharge: physiol (lactation/ H stimulation/ high prolactin) vs. pathological
• Skin changes: advanced malignancy (eg. Inflammatory carcinoma)

• Duration of symptoms: > 1 yr for malignant growth 1 cm (longer in elderly); Phylloides tumour: large in short time
• Progression
• Risk factors

1. Prolonged uninterrupted menses: early menarche, late menopause, nulliparity
2. Abortion
3. Consumption of H: eg. "Pill", HRT
4. Prev Hx benign br disease: atypical ductal hyperplasia (combined with prev Hx ca br - 6x higher risk than general population)
5. Prev Hx ca br
6. Fam Hx

• Lifetime risk

1. USA/ Europe 1/8
2. HK 1/20

• Social + Fam Hx

• Duration - when/ how 1^st noticed
• Change size?
• Painful/ tender?

• Site - lump/ whole of one/ both breasts (mastodynia)
• Effect of menstrual cycle on pain

• Discharge - spontaneous/ on expression (colour/ nature) (one/ both nipples)
• Crack or "eczema"
• Distortion/ retraction

• Menarche age
• Menstrual pattern
• Menopause age
• "Pill"/ HRT
• Preg details
• Br feeding

• FHx ca br?

• Traditional/ alternative meds (taken/ applied)

• Front of Pt - sitting (1) Rest (2) Arms up (3) Leaning fwd - hands in front (4) Hands on hips - fixicity of mass (also supine - inferior quadrants better, recline 45 deg - upper quadrants better)
• From clavicle to intra-mammary fold
• Symmetry
• Swelling
• Skin changes - dimpling, redness, peau d'orange (skin oedema - lymphatics blockage by inflammatory carcinoma cells), satellite nodules (advanced condition), colour change
• Axillary mass
• Lymphoedema (blockage of axillary lymphatics - cancer, surgery + radiation)
• Visible lump
• Nipple change - retraction, discharge (single duct most likely pathological - esp. bloody discharge, bilateral likely physiological, colour), Paget's disease, fistula
• Paget's disease: whole nipple eroded
• Bloody nipple discharge: mostly likely papilloma (benign) - single duct
• When there is nipple discharge, try to find associated mass (mass more important than discharge)
• Tethering/ attachment to skin
• Ulceration

• Systematic
• One hand only
• Flat (not tip) of fingers: pressure greater with tip
• Gentle (not forceful)
• Start with asymptomatic side first
• Cover all quadrants and axillary tail
• Fingers move in circular motion, radial as spoke of wheels

• Sit Pt up/ recline 45 deg
• Hold forearm with opposite hand
• Raise arm above head to tug fingers of examining hand
• Hold Pt's R hand, Dr L hand examining Pt R axilla (+ vice versa)
• Examine the anterior, medial, posterior + lateral folds (from front of Pt)
• Lateral: upwards, few LN, if lumps - usu. sebaceous cysts
• If lump - size (measure), discrete/ matted, fixed to underlying structure (determines operability)

• Lump - site (quadrant), size, shape, surface, consistency, tenderness
• Attachment - skin, pec fascia/ muscle (hands on , push down to tense pec, then test mobility)

• Axilla - palpably enlarged LN (4 groups)
• Supra-clavicular fossa (examine from behind Pt)

• Chest + RS
• Ab: esp. liver
• Spinal tenderness: bony metastasis

Give examiner a clinical staging at end of examination

Mass

• Side and size
• Position according to clock face
• Also with reference to either nipple or areola
• Eg. Left breast mass, 2cm in diameter, at 2:00, 3cm from nipple

Size + chance of malignancy