Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include:
Demonstrating empathy in response to patient cues: both verbal and non-verbal.
Active listening: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and offering them a seat).
Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.
Use open questioning to explore the patient’s presentingcomplaint:
“What’s brought you in to see me today?”
“Tell me about the issues you’ve been experiencing.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presentingcomplaint if required:
“Ok, can you tell me more about that?”
Open vs closed questions
History taking typically involves a combination of open and closedquestions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.
History of presenting complaint
The SOCRATES acronym (explained below) is a useful tool that you can use to further explore the characteristics of the patient’s breast lump.
Ask about the location of the breast lump:
“Where is the breast lump?”
“Can you point to where the breast lump is?”
Clarify when the breast lump developed:
“When did you first noticed the breast lump?”
“How long have you been aware of the breast lump?
Ask about the specificcharacteristics of the breast lump:
“Does the breast lump feel soft or hard?”
“Does the breast lump feel smooth or irregular?”
“Is the breast lump painful?”
If pain is associated with the breast lump, ask if this radiates:
“Does the pain from the lump move anywhere else?”
Ask if there are other symptoms which are associated with the breast lump:
“Are there any other symptoms that seem associated with the breast lump?”
See the keysymptoms section below for examples.
Clarify how the breast lump has changed over time:
“Has the breast lump changed in size or the way it feels over time?”
“Over what time period has the change occurred?”
“Is the lump’s size or discomfort related to the menstrual cycle in any way?”
Exacerbating or relieving factors
Ask if anything appears to have triggered the onset of a breast lump:
“Did the breast lump develop after a specific incident, such as breast trauma?”
If breast lump pain is present, ask if anything makes it worse or better:
“Does anything seem to trigger the pain?”
“Does anything improve the pain?”
Assess the severity of any associated pain by asking the patient to grade it on a scale of 0-10:
“On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”
Keysymptoms to ask about when taking a breast lump history include:
Nipple discharge or bleeding: associated with infection (e.g. mastitis and breast cancer).
Nipple inversion: recent onset nipple inversion is typically associated with breast cancer.
Erythema: associated with breast abscess, mastitis and underlying breast cancer.
Ulceration: typically associated with breast cancer.
Dimpling (peau d’orange): associated with underlying breast cancer.
Fever: may indicate underlying infection (e.g. breast abscess).
Weight loss: may indicate underlying breast cancer.
Malaise: associated with breast abscess and breast cancer.
Lymphadenopathy: typically involving the lymph nodes of the axilla and neck (e.g. breast cancer, breast abscess).
Bone pain: consider the possibility of metastatic breast cancer.
Ideas, concerns and expectations
A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.
The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.
Explore the patient’s ideas about the current issue:
“What do you think the problem is?”
“What are your thoughts about what is happening?”
“It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”
Explore the patient’s current concerns:
“Is there anything, in particular, that’s worrying you?”
“What’s your number one concern regarding this problem at the moment?”
“What’s the worst thing you were thinking it might be?”
Ask what the patient hopes to gain from the consultation:
“What were you hoping I’d be able to do for you today?”
“What would ideally need to happen for you to feel today’s consultation was a success?”
“What do you think might be the best plan of action?”
Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.
Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.
Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”
What you plan to cover next: “Next I’d like to discuss your past medical history and then explore what medications you currently take.”
A systemicenquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include:
Systemic: fevers (e.g. breast abscess)
Respiratory: shortness of breath (e.g. lung metastases)
Gastrointestinal: abdominal pain, nausea and vomiting (e.g. bowel obstruction)
Neurological: confusion (e.g. brain metastases)
Musculoskeletal: back pain (e.g. spinal metastases)
Past medical history
Ask if the patient has any medicalconditions:
“Do you have any medical conditions?”
“Are you currently seeing a doctor or specialist regularly?”
If the patient does have a medical condition, you should gather more details to assess howwellcontrolled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospitaladmissions.
Ask if the patient has previously undergone any surgery or procedures (e.g. breast lump biopsy):
“Have you ever previously undergone any operations or procedures?”
“When was the operation/procedure and why was it performed?”
Take a focused obstetric and gynaecologyhistory to identify riskfactors for breast cancer such as:
Treatment with continuous combined hormone replacement therapy
Not having breastfed
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).
Examples of relevant medical conditions
Medicalhistory relevant to breast lumps includes:
Previous breast lumps (including investigation results and management)
History of breast cancer
Continuous combined hormonal replacement therapy
Radiation to the chest (e.g. multiple scans or X-rays in the past)
Ask if the patient is currently taking any prescribedmedications or over-the-counterremedies:
“Are you currently taking any prescribed medications or over-the-counter treatments?”
If the patient is taking prescribed or over the counter medications, document the medicationname, dose, frequency, form and route.
Ask the patient if they’re currently experiencing any sideeffects from their medication:
“Have you noticed any side effects from the medication you currently take?”
Medications which increase the risk of breast cancer include:
Combined oral contraceptive pill
Continuous combined hormonal replacement therapy
Ask the patient if there is any familyhistory of breast, bowel or ovarian cancer:
“Is there any history of breast, bowel or ovarian cancer in your close relatives?”
Clarify at what age these diseases developed:
“At what age did your mother develop breast cancer?”
Family history of breast cancer in a first-degree relative is a significant risk factor for breast cancer. A number of genetic mutations are implicated, with BRCA1, BRCA2 and TP53 mutations associated with the highest risk.
Explore the patient’s socialhistory to both understand their socialcontext and identify potential breast cancer risk factors.
General social context
Explore the patient’s general social context including:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)
if they have any carer input (e.g. twice daily carer visits)
Record the patient’s smokinghistory, including the type and amount of tobacco used.
Calculate the number of ‘pack-years‘ the patient has smoked for:
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
Smoking is a significant risk factor for breastcancer.
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Alcohol is a significant risk factor for breastcancer.
Recreational drug use
Ask the patient if they use recreationaldrugs and if so determine the type of drugs used and their frequency of use.
Intravenous drug use is associated with an increased risk of developing abscesses.
Ask about the patient’s current occupation and assess the impact of their symptoms on their ability to work.
Closing the consultation
Summarise the keypoints back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.