BREAST CASE PROFORMA After taking informed consent, patient is in sitting position

with arms by the side of her body.

Name: Age: Sex: Occupation: Address: INSPECTION:
HISTORY 1. Breast: i: Position ii: Size and Shape iii: Any puckering or
dimpling iv: Any swelling/ulcer visible
Chief Complaints: 2. Skin over breast: i: Colour & Texture ii: Engorged veins iii:
Lump in the Rt/Lt breast since Dimple, retraction, puckering iv: Peau d’orange v: Any visible
Pain in the lump/breast since nodules vi: Ulceration/fumigation
Ulceration over breast since 3. Nipple: i: Presence ii: Position iii: Number iv: Size and
Nipple discharge since Shape v: Surface vi: Discharge
Swelling in the axilla since 4. Areola: i: Colour ii: Size iii: Surface & Texture
History of Present Illness: 5. Arm & Thorax
Patient was apparently asymptomatic __ days back when he 6. Axilla and Supraclavicular Fossa
developed 7. Raise Arms above head
1. Lump- Onset (noticed how), duration, progression, any H/O PALPITATION: *Palpate normal breast first* [Palmar
trauma, any H/O rapid growth surface of fingers with hand flat] Normal breast gives firm
2. Pain- site, onset, duration, character, relation with swelling, lobulated impression with nodularity. Now affected side:
relation with menstrual cycle Confirm inspection findings, Feel axillary tail just behind
3. Ulcer-like ulcer nipple
4. Nipple discharge- duration, type, from one opening/multiple LUMP: i Local rise of Temperature - Skin tenderness (local
openings, amount, foul smelling or not tenderness) ii: Situation (quadrant) iii Number iv: Size &
5. Retraction of nipple Shape v: Surface vi: Margins vii: Consistency, viii: Fluctuation
6. Swelling in the axilla ix: Trans illumination x: Fixity to skin xi: Fixity to breast
Any H/O chest pain, cough, hemoptysis tissue xi: Fixity to underlying fascia and muscles xiii: Fixity to
Any H/O pain abdomen, jaundice chest wall xiv: Palpation of Nipple Areolar complex xv:
Any H/O low back ache, ache in limbs, Ulcer
Any H/O headache, LOC, vomiting, seizures xvi: Lymph Nodes
Any H/O loss of weight, loss of appetite A: Axillary Nodes: 1. Pectoral 2. Brachial 3. Subscapular 4.
PAST HISTORY: Central 5. Apical
H/O similar complaints B. Cervical Lymph Nodes: Supraclavicular
-Any H/O HTN, DM, CAD ,TB, Hypo/Hyperthyroidism/ Epilepsy/ OTHER SYSTEMS:
Asthma/COPD/ / Blood transfusions CVS- Normal S1 S2 heard, No murmurs.
Respiratory: Normal vesicular breath sounds, No
adventitious sounds, GIT- Per Abdomen Bones- Normal
Drug and Treatment History: H/O previous surgery for breast
CNS- No Facial asymmetry, all reflexes are normal
FAMILY HISTORY: PROVISIONAL DIAGNOSIS:
None of the patient’s parents, siblings or first degree relatives have or This is a case of single, fixed, hard lump in upper outer
have had similar complaints or any significant co morbidities quadrant of rt/lt breast suggestive of carcinoma of TNM
stage with no evidence of local or systemic complications
Obstetric and Menstrual History= Age of menarche, age of [This is a case of single mobile firm lump in lower outer
menopause, marital status, number of pregnancies, breast quadrant of Lt/Rt breast, probably benign, most probably a
feeding, LCB, use of HRT/contraceptives fibro adenoma of the Lt/Rt breast.]

PERSONAL HISTORY: [Important] NOTES:

Diet, Appetite, Bowel, Bladder, Sleep, Addictions (Alcohol and Discharge from Nipple
Smoking), Any Allergies Blood – Duct papilloma, carcinoma breast
Pus – Breast abscess
PHYSICAL EXAMINATION
Milk – Lactation, galactocele, mammary fistula
1. GENERAL SURVEY
Serous/Greenish – Fibroadenosis, duct ectasia
- General assessment of Illness- ECOG (Zubroad scale)/Karnofsky
score) Retraction of Nipple
-Mental state and intelligence (CCC) Circumferential – Carcinoma breast
-Build, state of nutrition Slit Like – Mammary duct Ectasia with periductal mastitis
-Decubitus and Attitude, Any facies
[A __ year old patient, supine decubitus who is __ built __ Mondor’s Disease: Thrombophlebitis of the superficial veins
nourished is conscious, coherent, cooperative, and comfortably of the breast and anterior chest wall
seated/lying on the bed, well oriented to time, place and person] Cancer en cuirasse: Multiple cancerous nodules and
There is No Pallor, Icterus, cyanosis, koilonychias, generalised thickened skin like a coat of Armor in arms and thorax.
lymphadenopathy and no pedal edema. Tethering (Dimpling): Infiltration of Astley Cooper’s
VITALS: Temperature: Pulse, RR, BP. ligament, pulls the skin inwards creating a dimple or
puckering over the breast. Tumour moves independent of
LOCAL EXAMINATION-Breast skin.
Fixity: Infiltration of skin itself by the tumor. Tumor cannot
be moved, i.e. skin cannot be pinched. TNM staging: T4b
Peau D’Orange: Lymphatics of skin being obstructed.
Considered as skin involvement.
Level of Axillary Nodes:
Level 1-Lateral to lateral border of pectoralis minor
• Anterior (Pectoral) • Posterior (Subscapular) • Lateral
(Brachial)
Level 2-Behind pectoralis minor
• Central • Rotters (between major and minor)
Level 3-Medial to medial border of pectoralis minor
• Apical (Infraclavicular)
axillary lymph node metastases or metastases in Ipsilateral
supraclavicular lymph nodes with or without axillary or
internal mammary lymph node involvement
N3a Metastases in ipsilateral infraclavicular lymph nodes
N3b Metastases in ipsilateral internal mammary lymph
node(s) and axillary lymph node(s)
N3c Metastases in ipsilateral supraclavicular lymph node(s)
Chemotherapy: For all node positive cancers, >1cm in size,
triple negative cases, CMF REGIMEN= Cyclophosphamide,
Methotrexate, 5-Fluorouracil 28 day cycle

Inspection of the breast with the arms raised over the

head—to look for any nipple deviation or any skin changes.
Inspection with the patient sitting and leaning forward—to
look for whether both the breast fall forward equally or
there is fixity of the diseased breast.
Inspection with the patient sitting and pressing her waist
with the hands—to look for any evident skin changes.

Bi RADS (Breast Imaging Reporting and Data System)

1. Negative
2. Benign finding
3. Probably benign finding
4. Suspicious abnormality
5. Highly suggestive of malignancy
6. Biopsy confirmed malignancy

TNM Staging of Breast Cancer:

Tx—primary tumor cannot be assessed*
T0—no evidence of primary
Tis—carcinoma in situ (Tis DCIS, Tis LCIS, Tis Paget’s)
T1— tumour less than 2 cm
T2—Tumour more than 2 cm but less than 5 cm
T3—Tumour more than 5 cm in greatest dimension
T4—Tumor of any size with direct extension to the nchest
wall and or to the skin (ulceration or skin nodule and peau d’
orange). Invasion of dermis alone does not qualify as T4
T4a—Extension to chest wall, not including pectoralis
muscle adherence/invasion
T4b—Ulceration and or ipsilateral satellite nodules and or
edema (including peau d’ orange) of the skin which do not
meet the criteria for inflammatory carcinoma Sentinel lymph node is the lymph node which is in a direct
T4c—Both T4a and T4b drainage pathway from the primary tumor. Sentinel lymph
T4d—Inflammatory carcinoma node is the first node encountered by the tumor cells and its
histological status predicts distant lymph basin status with
Nx Regional lymph nodes cannot be assessed (e.g. regard to metastasis
previously removed) QUART is quadrantectomy, axillary dissection (level I-III) and
N0 No regional node metastases postoperative radiotherapy.
N1 Ipsilateral level 1 and 2 axillary lymph nodes (mobile) Simple Mastectomy: Surgical removal of the whole of breast
N2 Ipsilateral level 1 and 2 axillary lymph nodes that are tissue superficial to the pectoral fascia is called Simple
clinically fixed or matted or in clinically detected ipsilateral Mastectomy. That means superficial fascia is left behind or
internal mammary nodes in the absence of clinically evident not removed. Total Mastectomy: Surgical removal of the
axillary lymph node metastases whole of breast tissue including the pectoral.
N2a Ipsilateral level 1 and 2 axillary lymph nodes fixed to Modified Radical Mastectomy: Removal of the whole of
one another (matted) or to other structures breast tissue including the pectoral fascia and all 3 levels
N2b Ipsilateral internal mammary nodes and in the absence axillary lymph nodes.
of clinically evident level 1 and 2 axillary lymph node Patey’s MRM = P major is preserved but minor removed.
metastases Scanlon’s MRM= P minor divided, Auchincloss MRM=
N3 Metastases in ipsilateral infraclavicular (level 3 axillary) Pminor retraced but not divided.(Done nowadays)
lymph nodes with or without level 1, 2 axillary lymph node Halsted Radical=Both muscles removed
involvement or in clinically detected ipsilateral internal
mammary lymph nodes with clinically evident level 1 and 2