Breast History

Name

Age

Sex

Occupation

Residence

Marital status

Date of admission

C/o 

Right sided breast lump for 1 month

History of Present Illness

Local History 

Breast mass: Onset, Site, Initial size, How she noticed the mass, progression , final size , relation to cycle ,Other swelling in the breast in the axilla or  the ipsilateral upper limb .associated with trauma .fever .ulceration and discharge

Pain: onset duration .site severity character relieving and agrivating factors

Skin changes: redness scales onset duration site progression

Nipple discharge: color amount odor frequency spontaneous or induced unilateral or bilateral

Nipple ulceration or rashes: onset progression unilateral or bilateral

Hermonal History 

Age of menarche

Age of first full pregnancy

Age at first breast feeding and duration

Age of menpouse

Use of Hormone replacement therapy and use of oral contraceptive pills

Symptoms of Malignancy 

Wt loss .symptoms of anemia. 

Symptoms of Mets

GIT :Jaundice. Abdominal distension.

CVS+ pulmonary :Cough with haemoptysis chest pain lower limb oedema.

CNS :Loss of consciousness . Headache . Convulsion .

GU :Urine amount colour and frequency.

Past Medical History

Hospitalizations

Breast surgery

Breast biopsy

Exposure to radiation

Mammography

Regular follow up

Other surgical operation

Chronic illnesses

Family History

 Ca breast

 Other malignancy

Drug History

Tamoxifen

Chemoradiotherapy

Social History

Level of education

Job

Supporter

Smoking

Alcahol abuser

Health insurance