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OK, we can see your screen now. Ok, great. Um Hello, sorry for the technical difficulties. Um My name is Selia. I'm 1/4 year Medical student Imperial. And today I will be giving a talk uh on the neck lump and breast examinations uh which are very important examinations because they combine they are both perceived as examinations and also as clinical skills. So you might get joint stations in your um ACY circuits and more likely just because they form uh three distinct parts of um examinations. Uh most likely at least one of them will come up. So it's very important to have an understanding. Um and also they link to a number of pathologies and presentations that you are expected to be familiar with um at those at this age of your career. So it's a very good opportunity for you to have an overview of the conditions, what clinical uh features they have, how you take us a focused history and how um you tailor your examination to be able to uh produce a meaningful uh differential diagnosis. Um So the struct the structure of the session will be uh divided in two. So the first part will be for the neck and lump examination, which which includes hernias and the thyroid. Um and Part B will be focusing on the breast examination uh with an appreciation of the history taking which is an integral part of the examination. Um So we can start for the neck and lump. Um for the os you are expected to be able to perform summarize and record the examination of a lump. Um lumps can be uh in the periphery lipoma and sebaceous cysts. Um more most commonly but also in the neck, you might have lumps which are congenital infective and then specifically for the thyroid, which is presenting with lumps in the neck in the area of the neck and has a completely different pathology and implications with regards to management. Um It's very important that you are able to uh classify and differentiate the causes and also be able to comment on the appropriate steps to investigate the mas neck swellings. Uh and there are a number of conditions and pathologies. However, uh for the purposes of the O you are expected to be more familiar with the more common ones or the most important ones and these are the ones that we will be covering today. So, skin lumps, when you're taking history, it really depends on the size. Uh But it's always good to start with a general s inspired history um to be able to understand when that happened. What is the size. And if there's been any changes on its size or other characteristics and also pain and other symptoms that they may present with, it's very important to inquire upon um specific uh mechanisms that have led to that lump. So if there has been any trauma, any signs that there is an infection, any systemic signs that might indicate a malignancy or an infection. And then previous history from um either the childhood or family history of cancer, any previous uh sexual um uh any any previous surgeries. And of course, sexual history if your lungs are presenting in genital areas. So we can see here that there are a very distinct lungs across the body. We have uh lumps in the neck that we will be covering extensively. Then uh in the periphery in the skin, we might have lipomas which are fatty tissue. Um and then in the abdomen because of the laxity of the abdominal wall. It's a very a common sign to get lumps and bumps and depending on where they come from and their mechanism, they have different terminology and also sebaceous cysts which might be infected and should be managed uh more aggressively. So before the examination, as with any examination, uh the first thing to remember is to wash your hands and wid, especially for these examinations where you're coming in close contact with something that's potentially infectious. Uh It's more, it's even more important to show to the examiner that you're taking all the steps to protect yourself, but also uh the person who's being examined. Um So the first thing that you want to do when you enter a circuit is to wash your hands and watch around for any BP that they might expect you to wear, then you will uh proceeded with your normal uh introduction to include your name, role and task. Uh And it's very, very important to remember that whenever you carry out an examination, you have to detail every step or generally the, the, the general steps to the patients that they expect what is to come and also why that's indicated. Um Then you would want the patient to know um the exposure requirements. So which aspect of their body would be exposed? Um And also to offer a aone and make sure that you have an informed consent from the patient when you're carrying out these examinations because you're coming very close to them and you're taking a very close look and they have to feel safe and dignified. Uh So after you tick all those boxes in your mind, um then you would wanna position the patient. Um So for these examinations of the lungs, it depends on the side. But generally, um you might, they might be either seated or if you want to take a closer look or it's something in their neck, you might want them to be laying on the couch on 45 degrees. And finally, before you do anything else and proceed with the steps, you need to ask for pain so that you are able to manage that during the examination. But also to have that in mind when you're, when you're making your different cell diagnosis. So for a lump assessment, um it's very critical to remember the six assay. So those are size side shaped smoothness, which means consistency, surface and surroundings. For the size, you might be given a tape and you might take the diameters uh the diameter of the lump. Uh the side you will note on the document of that you are given or when you report to pa to the examiner, you'll be noting where that lump was and then the safe, whether it's uh very well or ill defined, uh then you will de describe its consistency. So what it feel, it feels like when you squeeze it within your fingers um and also on its surface, what it looks like, what's the color and what are the edges? And finally, um the skin around um if there's any erythema, any ulceration. Um So when you think about of the six acids, you think about mainly the lump, but also what's around the lump and what's the interface between those two? Uh it's very useful. Although the ABCD um pneumonic is used for the to differentiate between a mole and the Melanoma, it's kind of similar to the sex assays. So that's kind of useful to remember as well. Um So ABCD um is also for as symmetry uh borders um color um diameter and everything else. Um So that's those, those are two pneumonics to remember when you're assessing any lump or any lesion in the skin. Um But then you will also have to settle in with some further features. Um So then comes the pneumonic with the three S S3 s3 DS and one F. Um And that is because there are special characteristics that might help you understand what's inside the lump. So for example, translumination, like lighting, se setting a light on the lump might help you understand whether it's something that's fluid filled such as the hydrocil. And that's the same thing when you're pressing to assess for fluctuation, then there are some signs such as temperature, something that's hot means that it's inflammatory or infective or tender, which is again, something that feels very tense. As for example, a strangulated carnea, um tethering is a, is a characteristic of a lump. Uh on that it's fixed to its surroundings. Uh It's tethered when it's uh a to the surroundings and fixed when it's to the abdominal wall or the wall. Um And that's very crucial to understand because that implies the uh invasiveness of the lung. And finally, if something is pulsatile, then you're thinking probably of an aneurysm. If it's in the neck, probably a carotid aneurysm. If it's in the abdomen and abdominal aneurysm and auscultation, you might auscultate in the neck, um laterally for a carotid aneurysm. And these are all things that you are expected to do. Um, if the history and the examination is suggestive of anything of those, um, and it's important to have them in mind in addition to this I A that we've uh discussed before. So which further assessments would you uh complete? Um, would you do to the complete an examination of a lump? Uh I'll give you uh a little a few seconds to think about it. So, after you completed the examination, you've had the assessment of uh of all the features, what extra things would you wanna say to the examiner that you would do if you had the time or um the expertise to do that? So first thing you would wanna assess a law neurovascular function. So that is if the nerve system and the vascular system are working properly, that would it uh be to um exclude any possible obstruction or strangulation in a hernia in the abdomen? For example, then you would check for lymphadenopathy. So any other swellings in the body and bruise bowel sounds which you can do. Um if you have the time for the carotid or other reasons, there are however, some special lumps which might come up in your ay. Um and they will definitely come up in your exams because they are very, very common and very important to have an appreciation in clinical practice. And this is hernias which occur in different sides of the body, but mostly abdominal hernias is what we are being taught and deal with on a daily basis. And from all the hernias, the inguinal hernias, which are the commonest and the femoral hernias, which are the most um important ones to beer are the ones that you should be more familiar with. And then for the thyroid, um so that the thyroid is a gland that sits on the midline of our neck. And upon thyroid dysfunction, you might have uh different changes. It, they might be unilateral or bilateral um and they might point to different diagnosis. So when you are being tasked to examine the neck, you should have those in mind. Um in the in the history, you should ask questions to establish thyroid function. And then in the clinical examination, you should have an understanding of if the thyroid is enlarged holistically on one side, what it is, what does it feel like? Because it's very crucial to form an I uh valid uh difference of diagnosis. So, a hernia, um a definition that you will be tired of hearing uh until the end of your career probably is that uh the definition of a hernia, which is the protrusion of a viscous from its containing compartment into an abnormal position by a defect, taking its coverings with it. So, in the abdominal wall, um when there are some risk factors for laxity, for example, uh, for when someone is lifting weights or after pregnancy, when the abdominal wall becomes extremely loose, um, you might get some of the, um, the excuse to go out through a hole. And depending on whether that's a coming go that's able to be retracted or not, we define them as either reducible when it can be manul in either manually or on its own or irreducible when it's like stuck there. Um, and then progressively, um if it does uh become irreducible, so it doesn't go back as you understand, depending on what aspect, what fiscus is being entrapped, you might get obstruction, which is usually the term um used when there is a part of the bowel, uh being herniated because then that part of the bowel is not patent and we get bowel obstruction and symptoms. So, if you have a patient who's presenting with a lump in their, in their abdomen and uh nausea and vomiting, that's highly indictable for the bowel obstruction versus strangulation, which is more about ischemia. So, uh inadequate blood flow. So then the Mark syndrome syndrome is uh symptom is pain. So, you will have a patient who is in much pain and visibly unwell and that's a surgical emergency. Uh So as we said before, um, inguinal and femoral hernias are probably the most uh high yield hernias that you will have to study for, uh because they are very close in proximity and the anatomical landmark used to differentiate between them is the pubic tubercle, which is the lateral aspect of the pubic symphysis bilaterally and depending on whether it's above and medial where it is the inguinal um hernia or below and lateral. We differentiate between the two. However, there are also so many epidemiological characteristics. So males are more prone to inguinal hernias, whereas females are more prone to femoral hernias. Um and whereas inguinal hernias are more common, uh femoral hernias are surgical emergencies and always uh require um surgical management and the appreciating the anatomy and being able to differentiate between them is very important. It's highly unlikely that something like that comes up uh on the patient uh in, but they might ask you how you would differentiate between them or how you would manage them. And this is a very high yield um aspect of hernias that you should be familiar with. So, clinical features of hernias, uh the risk factors, as we briefly said before are um anything that makes the wall more uh like like more flexible or anything that might cause a viscus to get out of its place. So, chronic cough, heavily and excessive straining are the most key factors to remember. Uh Then when you see in clinic, someone uh who is having a hernia, usually they have some sort of pain, especially when they are um coughing or when they are straining. Um And then they might have some change in bowel, which is however, indicative of an obstruction, they might uh you know, say something else uh comes and goes so that make you think that uh that it is, is a reduce hernia. Um And in further stages, they might have a burning sensation or even a scrotal swelling. Um when you need to uh appreciate and communicate that this is uh a much more advanced uh stage in the hernia. And there is usually a surgical requirement. So when you're primarily taking a history for a hernia or doing an examination in the OS, you should make sure to look for and note any signs that couldn't indicate obstruction. And if you don't find them, communicate them because that indicates that this is not the hernia that you would be worried about in clinical practice. So the examination steps begin with an introduction as usual. Uh It's very important to offer a chaperone because you might need to expose some very intimate um parts of the patient. Um So it's very important to offer a chaperone in your introduction. Then in the inspection, take a look around if there's any stomach bag, anything that's suggestive of a baby surgery because surgeries are also risk factor for hernias. And also there are uh stomas are in, in a sense, hernias that are made in the surgery. So you might i in a hypothetical scenario, be asked to either examine one or comment on one and then you will need to after doing a general inspection closely closer to the hernia and use the six S as with any lump. Um and also something that's very useful to remember always with hernia is that they are more pronounced when you cough. So you always ask the patient to cough and especially when they are laying flat on the bed. So you ask them to lay flat and cough so that you're able to see if the hernia is uh protruding. then on palpation, uh if it's in the groin, you need to find the midinguinal point, which is the midway through the ace in the pubic synthesis. Press on it and understand hypothetically whether it's um a deep uh an, an indirect or direct inal hernia. So a direct is not passing through. So it's not contained. But when you're pressing and it is contained, then you know, it's going through that canal. So it's the indirect uh imal hernia. Then you would also wanna have a closer look to the um her to the hernia and look for any signs of pain, temperature, consistency, positivity, possibility how it it it uh changes with a cough. So if it doesn't change with the cough, then maybe it's strangulated or just nonreducible and then also no, the structures around that. Um It's always a good, a good idea for these examinations, for everything that you don't feel quite confident in doing uh or when you wanna, so that you understand that some things are very intimate um, you might ask the patient to do something for you. So for example, you know, I, instead of using the hernia on your own, you might ask the patient to do so, if they say that they are using it on their own, um, of course, if they, if they've never done it, it's not, um, very valid to ask them to do so. But if they say that I have this hernia and that when I press it in and it just disappears, then they know how to do it and they can show you how they do it instead of you doing it. And then auscultation for bowel sounds, especially if there is a hernia in the abdominal area to exclude obstructive features. And for the end, you wash your hands. Thank the patient and complete the examination with an abdominal examination, examining the contralateral side to the hernia. And also if it's relevant and if the patient is male, examine the squat moving on to the neck for the thyroid and neck uh lumps, um It's very important to remember that the triangles and their, their um borders. Um This is a very, very, very common question in exams. And after it's an examination because it relates to the anatomy. But it's, it's also important because different pathologies appear in different aspects of the neck. So in the front of the neck, uh which is characterized by whose borders are the midline, the mandible, the op the mastoid. Um we get most things from the salivary glands and the carotid glands which are up in the face. And it's also where the carotid lies, where any carotid pathology will be demonstrated at this triangle and also anything on the midline. So, a thyroglossal cyst, a dermo cyst uh will be manifesting on that triangle. The posterior triangle has to do more with the ribs. So it's behind the tele mastoid, uh it ends at the level of the trapezius and it defined by the clavicle. So then you would have any lymphadenopathy with. So because the lymphatic chains um go through that triangle and also any uhn pouch, which is basically a remnant would be on that aspect. Um So, in the history, it's very important again to um think of Socrates and ask how long they have the uh the lump in their neck if it's changed in size or any other characteristic. But also because the thyroid gland in the neck, we always ask questions um to establish symptoms of either hyper or hypothyroidism or any history that they have ever before. Then you would wanna think about other symptoms, more generic. So any referred pain to the ears, any visual changes, any weight loss and any smoking history, which are um risk factors for thyroid cancer. Uh red flag uh symptoms that you should ask for and have uh think about is stridor. Uh something that a rapidly growing mass lymphadenopathy, uh hoarseness um and anything that appears in Children, uh anyone who's, who has had previous radiation exposure and if there is um family history of thyroid cancer, so, thyroid cancer is an increasing in prevalence and especially in young people. So all neck lumps should be considered for a possibility of malignancy. So always, when taking a history, it's important to ask about systemic symptoms that you would ask with any malignancy, but also for family history, uh radiation exposure and any signs of hoarse since rider, which indicate that there is some sort of obstruction and progressiveness in the lung in the lump. And this is important to keep in mind of because uh for example, in my last year, when I had the breast exam, they asked me to also take a brief history and that's also very relevant for the neck examinations because they are far less um timely than the bigger examinations. So if they're asking you to take, to do an examination of a lump, it won't take you the full 10 minutes. So they might ask you to take a brief history because there are some things that you cannot just elicit from looking at the, at the lymph. So when you do, however, um move on with your examination, you for the thyroid exam or the neck exam in general, you'd need to do a general inspection for that. The patient needs to be seated. There's um no way to, there is no reason why you would want the patient to lay from the beginning because that's not allowing you to have a full picture of how the patient is acting. And that's important because now, uh as we said, we need to establish whether there are your thyroid, hyperthyroid or hypothyroid and signs of hyperactivity such as agitation, anxiety and fidgeting will only show if the patient is lying in their natural position, seated. Um Then you would have uh you will need to uh establish a systematic approach of, of looking around the general in the general inspection. So around the patient and then on the patient start, I usually start with the palms and then move all the way up to the face and neck. So from the palms, you are able to understand the tremors. So you're doing this using a paper um that you're laying on the hands and see if there is tremor in the hands and also by taking the pulse and establishing whether there is possible tachycardia or bradycardia. Um then moving up up further, you are able to appreciate whether there is palmar erythema ery thyroidopathy, which we see in the picture uh which are both signs of uh graves disease or hypothyroidism. And then in the face, um dry skin with hypothyroidism, uh versus sweating and hyperthyroidism or loss of the outer one third of the eye of the eyebrow hair is hypothyroidism. And then the eyes are also very important because um there are a lot of signs of hyperthyroidism in the eyes. So, Opals, which is the protrusion of the eyes, um lead traction, which is when the lead is somewhat. But we use, we usually colloquially say lazy and lead lab, which is when you're asking the patient to look down the lead is lagging. So it doesn't really follow all these are signs of hyperthyroidism and you should um uh assess for the for those in your inspection that you're carrying out in the thyroid examination. So at this stage, uh you've uh basically covered all the aspects of inspection until the neck. So you did the hand, this is the test with the paper for the tremor. You will look at the eyes for esophagus, um leg reduction and J and leg L and then you're moving on to the neck and the actual inspection. Um So you should um also have here a systematic approach in looking from all the sides. But really a focus should be on the midline of the neck to look for scars and any changes and everything minus swellings. And then the important thing to remember for the neck and thyroid inspection is that you need to ask the patient to do two things. So one thing is that they uh need to swallow, you can either tell them to pretend that they're swallowing or for some patients, it might be easier to give them uh some water to swallow. Um And then you should look in the neck and see if whatever lump they're presenting with is moving because if it's not moving, it's tethered. Uh and it's a different diagnosis from whether when it's moving. So a thyroglossal cyst would move, a thyroid mass would move. But lymph nodes which are anatomical structures embedded on the neck, they wouldn't move. And then the second thing that you need the patient to do is to stick their tongue out. And that's important because that should be he that is basically um help you diagnose a thyroglossal cyst. So a thyroglossal cyst um especially in a young person, uh would be um uh the diagnosis with anything that could move along the midline. Uh because the thyroglossalis essentially is a remnant of the thyroid uh duct. So patients usually present in their childhood, but many might not um have presented before. Uh So if you have a young patient with a cyst that is moving up and down where they're sticking their tongue, um It's a probably thyroglossal cyst, but you always do investigations for any um more pertinent diagnosis to exclude them and then diagnose a thyroglossal cyst. And finally, uh you need to palpate the neck. Uh usually, um you need to use your three middle fingers and you do this by going behind the patient. Um because you wanna focus on actually palpating and not just visualizing because you've already done your inspection. So you wanna feel for the size and the symmetry of the thyroid glands and any lumps, uh you're gonna feel for their consistency, how solid, how hard they uh they feel like in your hands. And also there is a probable thrill. Uh You also need to appreciate the anatomy in the neck. So you need to be able to define whether the thyroid cartilage ends where the cardi Caraco cartilage begins, where is the isthmus and the distant lobes uh on each side. Um And then again, you ask the patient to drink some water and protrude the tongue because you wanna feel whether what you've seen in the inspection is confirmed by your palpation. And as I said, you might also offer or actually also do lymphadenopathy assessment of the cervical chains and also look for a tral deviation because some lumps when they are uh very extensive, they might cause the trachea to deviate. And at this stage, um you are entering the final aspect. So after pro patient auscultation for any thyroid bruit or any carotid bruits, um and then it's very important to remember that for a thyroid exam, we are essentially assessing the thyroid as well and the thyroid has manifestations elsewhere in the body. So after you've moving away from the neck, going back away from the patient, you need to remember to check for three things for the reflexes but and hyperflexing hypothyroidism. Um so you can do either the biceps or the, the knee reflex. Um And then uh prox uh edema, which is those cha uh changes in the legs, which causes, which cause them to be very red and inflamed. Uh or for proximal myopathy. When you ask the patient to cross their arms and just by uh uh laying on their feet, being able to stand up, because if they have myopathy, they will have a difficulty doing. So, just to know that when you cult take for any bruise on the neck, you should be using the bell because it's a very uh small area. So you wouldn't use a diaphragm for this. Um And also when you put, I forgot to mention that we also need to per cast. So as with any other examination um in the thyroid, you need to remember the acronym of PA. So that first you position the patient doing stats, you palpate um you percuss. Uh So you would need to percuss uh and from the sternal um not down to the uh cari the coronal level and also from the midline up until the axilla to know if there is any uh other um uh notes that you should uh that should inform your diagnosis. So for the thyroid and neck, after you complete your examination, most likely you will get some sort of question about how you would investigate the patient. Um It's always a valid answer to um a name, uh thyroid function tests. And also remember to always um divide your investigations in bedside, uh noninvasive and invasive. So, starting with the bloods definitely do a thyroid function test. Also, you might wanna do blood uh full blood count and CRP for an infection and inflammation. And also consider uh serology for viruses because viruses can present in the neck. For example, um A B can be present in the, in the bre in the uh neck. Uh but also anything else might cause a limy in the neck. Um endoscopy is valid. Um We are discussing about internal uh lumps which are unlikely to come up in the os. But in then any other scenario, they are very valid um investigation to volunteer and then imaging primarily ultrasound, but also CT and MRI. Uh And finally, you would uh do either a biopsy if it's a, a big uh lump or most likely um you will do a fine needle aspiration cytology. We're using, I'll get the guidance of the ultrasound, you're taking some cells and you sent them for your histology and they are informative of whether there is a malignancy or not. Um It's also uh uh good to appreciate ultrasound in thyroid. So that's um the ultrasound has the power to um so any granularity, any enlargements and also any changes in vascularity, which are important to see if there's something unilateral bilateral. Um and if there is any multinodular or uh uninodular disease. So, here are some clinical scenarios uh to have a think of um um So let's say we have a 45 year old male who presents with a round painful lump on the back of the neck. Um The lump is smooth and flax with a visible central punctum. Uh The overlying skin is erythema and going to touch. So the last ones are indicative of an infection. Um So just by that, uh you can exclude the lipoma, which is a very benign um condition and it's either in fac sebaceous cyst or a reactive lymphadenopathy. Um So, moving on to the other scenario, on the examination of the neck, a patient presents with multiple painful le neck lumps less than one centimeter in diameter. Um So in this case, because we have many uh it wouldn't be an infected sebas cyst because it's very unlikely that you have a number of cysts and they usually much greater than one centimeter when the be when they are inflamed. So that leaves us with an infected sebaceous cyst for scenario one and the reactively up with scenario two. So the f the 52 year year old female with a small, a smooth soft lump over the right scapula, uh which is painless and more bile and does not translumination. So it's not fluid filled because anything that's fluid filled is translumination. So it's not, if it's not translumination, it's something that's denser. So it's fat. So it's lipoma. So these are the kind of um things that you should be looking in clinical scenarios because there are some keyboards that are here when you establish what is what um as they all present in the same location. Um So these are the keywords that you should be noting for these three very important diagnosis. So an infected sebaceous cyst usually has a central function. So that uh aspect of the uh white aspect um on its surface. And when infected, it shows the typical signs of um redness and warmth to touch. A lipoma is painless, completely benign. Um and does not translumination. Many people have lipomas and they are rarely um removed unless there are cosmetic uh indications and finally reactive lymphadenopathy. So, when the lymph nodes become uh inflamed in reaction to um any sort of viral or bacterial infection, um where you have a swelling, that's because of many small painful um neck lumps. So, benign presentations, as we discussed, lipoma is very common. Um It's important to know that if you have um a lump on the scalp, palms or soles, it cannot be a lymphoma. Uh so that uh due to the fact that there cannot be much um fatty tissue in those um parts of the body. Uh So if you have any of those, you are pretty confident in saying that it's not a lymphoma. So it's something different and generally they are investigated very conservatively. So you basically just watch and wait and you only need to remove them if there are cosmetic reasons or compressive symptoms. So, if they occur at the site that's causing compressive uh symptoms, then you might consider to remove them, uh epidermoid sebaceous cyst. Uh as we discussed has its uh central punctum as a very characteristic um connotation. Um And they might also cure in the skull. They tend to be quite bound that if they do become infected, um you need to either drain them or give antibiotics to cover for uh staphylococcus. And finally, the thyro cyst, which is a random of the thyro closes duct um is uh moving upwards with the production of the tongue. And that's the most important characteristic to remember. Um You would generally remove it, um especially because it's causing um it might be uncomfortable or it might cause uh some symptoms, but usually this is something that would be diagnosed in Children. Um And if you tend to find something like that in adults, um you should still exclude any other pregnant diagnosis. Um, a goiter is defined as the enlargement of the thyroid and as we discussed before, it can either be diffused or nodular, um it should prompt you to uh investigate whether the patient is your thyroid, hypothyroid or hyperthyroid. Um And the most common uh uh cause uh cause of a goiter worldwide is iron deficiency. Um But it can also be in uh graves disease. Um and other uh conditions usually with uh hypothyroidism. Um you would do a thyroid function test for this and also take some cell sample, you know, to be able to differentiate between malignancy and thyroid dysfunction and finally, thyroid cancer. Um One thing that's very, very remember uh important to remember because you might be asked and it's very important to just recall is that papillary, um thyroid cancer is the most common one. And that ii deficiency is the most uh common cause of follicular cancer, which is the second most common uh type of thyroid cancer. Uh Thyroid cancer can present in many different types and forms. It can form with, it can present with a go or several thyroid nodules. Um It's more common in women and when it progresses, it can cause symptoms of dysphagia, hoarseness, rider and weight loss, um because of the compression that it causes and the inability of the person to drink. Um So in the, the investigations would again be thyroid function tests, um which might not be the range in cancer. Um uh and that's not paradoxical because um thyroid cancers are not functional. So they wouldn't typically produce changes, but there are some cases you might see some changes. Um The idea of doing thyroid function test is that you want to exclude cancer rather than diagnose it because in order to be able to diagnose cancer, you would need to take some sort of sample. So either through fine needle aspiration and also with ride imaging, which we have some vectors. Um you are able to appreciate uh when you can, what you see whether, what you see is the result of an enlargement of a bilateral pathology, unilateral pathology, whether you have um many nodules or one nodule. So, um we've mentioned this before, just a refraction on which anatomical structures used to differentiate between an inguinal and a femoral hernia. And the answer is the pubic tubercle. Um So this is um the aspect where the um the end topical structure where you can actually uh differentiate if something is above and medial, then you would say it's an immuno one. And if it's below and lateral, it would then be um a femoral hernia. And that's a very, very important thing to remember. It comes up a lot and it's um just a AAA matter of recall of recall and me. So now uh we will be moving to part two of the uh tutorial which we will be focusing on breast examination. Um Interestingly, this was a session that I was not expecting you to get last year. Um because it's um it's very uh weird to think about how you will get that. So you might get a real patient. Um You might get a model and you might get a mo uh a patient wearing the model of the breast on them. And the latter is what happened with me. But what actually p me is that when I read the brief, they wanted me to take a history. And then the examiner told me which aspect of the breast examination they wanted me to do. Um So this is because um a breast examination on its own without any clinical context, any context of the patient um is not able to yield um a little of differentials. So most likely if that's something that's going to come up, you will have to, to some, to have to make, to have some sort of history taking beforehand or take some history yourself. Um And it's important to ask for the things that you wanna exclude. Uh but also to look for them clinically in the examination. So the anatomy of the breast um uh microscopic lens, not that um that's complex because it's just quadrants and the axillary tail um on the upper outer quadrant. Um And then microscopically we have the ducts which uh take, um which take in the lactation, the from the nodules uh away to the nipple. Um So the most common um area where you get breast cancer is the upper outer cad. Um And that's also something to burn in the brain. And remember because that's something that we might ask you or something that you might um think is in. So if you get a, a lump there, uh you might think that it's more likely to be breast cancer, but that's not exclusive. Um And then the aspect in the microscopic anatomy that you should consider is the ducts. So the ductal um uh breast tissue is the one that's more prone to cancer or at least more uh where we get more uh cancer diagnosis from. Um So, breast pathology, uh you should be able to PC that it's quite um it has a variety in the spectrum that is followed. So you will get patients just presenting with some tenderness or some pain. You will get patients presenting um when lactating, when breastfeeding, uh you will get very young patients. Um And yeah, you will get some old patients. Um So these are important uh to consider when you are telling your differential list because breastfeeding is a, is um a state where the breast is very functional. So it might lead for example, to mastitis. But as we grow older, um cysts for example, are much less likely to um occur. So that might indicate that there is something more sinister going on. Um So having those uh five points in mind are important on what you might encounter when you are being told that you are gonna present a lady who has a breast lump um or a breast uh breast pain. So, mastitis is the painful inflammatory condition of the breast. It can be infectious um especially in women who are breastfeeding a term lactational mastitis. Um it can cau and it can be caused by uh milk stasis. So it's important to establish whether the woman that is presenting is breastfeeding or recently given birth. Um but mastitis can also be non infectious. So either as a reaction to a foreign body or in the idiopathic ranma. Um inflammation form uh an abscess is a compli a complication of mastitis. Um and anapis would actually be, what would the um specific management with incision and drainage antibiotics and analgesia, whether mastitis is generally uh conservatively managed, um unless uh not responding and then it's important to differentiate those two with inflammatory breast cancer. So that's um uh fairly common. Uh I would say condition where cancer cells block the lymph drainage. So they are causing an inflamed area of the breast. Um So that might mask cancer, that you are diagnosing as mastitis, but mastitis um is inflammatory. So you would see fever, you would see chills, you would have an elevated white cell count. So if you have a ne neither of those, then maybe it is inflammatory breast cancer. Breast cyst um is very common presentation in women who are over 35 because it's caused by the estrogen causing an excess fluid production and fluid um filling the lobules and causing the cysts. So that's why we are not so much seeing that in menopausal women unless they are on hormone replacement therapy. So that's important to ask when someone presenting with a lump, if they are on HRT or if they are on um contraceptive pill because that might mean that they have increased levels of oxygen. Therefore, an increased risk of, uh, for, of creating, um, of having cysts even if their age is not uh likely for them. Um, if you are very young and have cysts, you have a small increased risk of breast cancer, but they are generally benign. Um, and you investigate with them if you're under 40 with an ultrasound and if you're over 40 with a mammogram and an ultrasound of the mammogram is not uh definitive or indicate or desired. If they are very large and painful, uh you might use an ultrasound to um aspirate uh the fluids and if it's still refilling or it becomes blood stains, uh then you would biopsy and excise um the cyst and also send it for histological procedure because um these are more on the term of red symptoms rather than benign symptoms that someone would present with a breast cyst. And finally, breast cancer, which is the diagnosis that you definitely wanna exclude to any uh person presenting with any sort of um breast tenderness or breast lump is the most common type of cancer in women. And its second most common uh type of cancer wor worldwide. And most presentations begin with a breast lump that is actually painless. Um So the most common type of uh cancer is ductal uh invasive cancer um that is now termed nope type cancer and everything else you see blue. Um as well as those uh very rare types are called special type because they are far less common. Um So when you're thinking about breast cancer, it's either ductal or lobular depending on the anatomy. And then depending on the, on the, on the elements or on the degree of invasiveness, you either have invasive cancer or in situ which is not progressing uh progress uh not infiltrating um for uh ductal cancer. The invasive one is the most common one, as I said, then in situ is the one that's usually presenting on just one breast uh versus the lobular one which is usually presenting bilaterally. And it's more common in premenopausal women. Uh part of the nipple is a very important uh and fairly common um eczematoid change of the nipple uh that can be seen with cancer. So it's uh associated with breast malignancy in 1 to 2% of patients with breast cancer. And out of them, 50% will have, will have a mass lesion uh which will be 90% invasive and even the rest of them uh will still have some sort of carcinoma. Uh The difficulty with that is that because it's an eczematoid chains, it might actually be eczema. Um And in order to die, to differentiate between the, between the pagets and eczema, you could need to do a punch biopsy. Um But in any case, if you see that or if in os station, they told you that they are presenting with nipple changes um with which are dry erythema and alterative skin then you might say that this is highly negative of Paget disease. I would do a punch, a punch biopsy to differentiate or exclude eczema because that's as that's associated with the breast malignancy, an invasive one as well. So just a a refresher from the uh thyroid uh examination. So let's just say that your roommate jokes about having an Adam's Apple which moves when she protrudes your to. So obviously, um as in the brief, it's indicated that she's a female, so you shouldn't have an AOM apple. Um So what's the congenital uh pathology that she's presenting with? Uh And that's the thyroglossal uh cyst, um which is uh the random of the thyroglossal uh duct uh which is basically not closed. So it has a protrusion in the midline of the neck and there is fairly still a number of patients who live with thyroglossal ducts. So they do not present until they're much older than Children actually. Um But moving back to breast cancer and Red flags when you're examining a lump in the breast, um something that's worrying you is something that's new. Um And something that's acutely presenting, um something that's irregular and how it feels, something that's in the upper outer quarter, but not necessarily definitely something in the underarm area because that might indicate metastasis. Um And the characteristics that are mostly uh indicative of malignancy are something that's very hard, very illdefined and very fixed to its surroundings. But then you should also appreciate any nipple changes. So any bleeding, any discharge, especially if bloody, any inverse radiation or flattening of the nipples and the positive disease of the nipple, which are the eczema changes are things that you should show that you are appreciating when examining the breast, skin changes around the nipples. So any skin dimpling, puckering or irritation and a poo, which is when the skin resamples, the appearance of an orange are also uh very indicative of malignancies um and should be uh appreciated when doing an exa an examination. And finally, you would want to ask or note any signs of metastasis. So any weight loss, any anorexia, uh bone pain, jaundice, unexplained, fatigue or shortness of breath. Um These are all symptoms that are being caused by metastasis of breast cancer. Um Just um so these are some points that included because it's um very likely that you'll be asked some questions if you're asked to uh examine the breast. Um general aspects of how we manage um patient presenting with breast. So there is a screening program under the NHS for women, 50 to 70 years old. So they are offered a mammogram every three years and after 70 they are still able to make their own arrangements um to have one. However, nowadays, just having one family member uh with breast cancer does not mean that that you need to be referred. So you need to have an extra of the following um characteristics in your family history to um be uh screened for uh family for breast cancer without having any lab. But if you do have a lump, the clinical pathway, um I remember it was 123. So usually starts with primary care. So a patient presents to the GP with a lump um and you have to assess whether they did they are um meeting the criteria for a two week wait referral. Um So this is a summary of when you need to do a referral, when you might consider that and when you wouldn't do a two week wait, that you might still refer. So, if you have someone who's, for example, under 30 years old and they have a breast lump, um that's unexplained. Um then you would do a referral but not under the two week weight. Um You would consider the two week weight if there are any skin changes. So any dimpling, any Paget disease. Um And anyone who's over 30 who has a lump in their axilla, you might consider that because that I told the metastasis, even though there are not many uh signs in the breast itself and definitely do a referral when you have anyone over 30 with an unexplained breast lump and anyone over 50 who has uh a breast lump, but also need to have any one of the symptoms that follows or any discharge, any retraction and any changes in the um axilla, uh nipple and skin surrounding. And following the two-week fight, we do a triple assessment that's usually nowadays done in one-stop clinics uh where patients go and have history and examination by a breast surgeon, um imaging. So, if you're under 35 most likely an ultrasound and that is because the breast is much denser. So um an ultrasound is more appropriate, appropriate. Whereas when you're over 35 you put in the mammogram. Um And then finally, you would either go under a core biopsy or final aspiration. Uh depending on how uh big the uh tumor. Uh the lump is and do appreciate whether there is a malignant malignancy. A question that you might get um following um a breast cancer examination is when you would do um uh clinical um and lymphadenopathy clearance, a lymph node clearance. Um So, if you can clinically establish that you could say that yes, I would do a clearance of the axillary lymph nodes. However, uh if you're not able to um confirm that clinically, you would need to do an ultrasound and take a sentinel lymph node biopsy. So take like one card uh lymph nodes to see if it's positive and then go on to a full uh lymph node clearance. And the reason why um axillary uh lymph node clearance is not the standard is that it can still cause with arm lymphedema and functional arm impairment. From the fact that you are depriving the area of lymph node drainage. So it wouldn't be something that's standard care for anyone having any lesions. Um The staging system used for breast cancer um as with any breast cancer uh is a TNM. So tumor size lymph nodes and metastasis and it's uh useful to appreciate the extent of growth and also direct management. Um This is just a very uh brief uh summary of how you might manage a breast cancer if you have any questions following your examination or generally for your exams. Um And there is the surgical aspect, well, the surgical aspect, radiotherapy or chemotherapy and then of course medication, which largely depends on the receptor status of the cancer and whether you are before menopause and after menopause. Um and this is just for your uh own reading and understanding of um how you would manage breast cancer. Uh However, what's very important to know is that all women and men undergoing breast are reco uh breast uh surgeries should be offered reconstruction. Um And that's something that you should note. Um if you're uh are in a station, for example, that has to do with communicating a surgical procedure. Um So, moving back to the actual breast examination, which will usually involve some sort of history taking again, think of Socrates in the six ss for any lump. And then you will have a full list of questions that you wanna ask the patient. And also when you move away from the lung. Think about the nipple, think about the skin. Uh ask about any discharge and ask in detail. So how much dis discharge when you get that? Do you press it or does it get out on its own? Is it any particular color? Ask for any trauma? Uh because that might indicate have necrosis um and ask for any systemic red like symptoms. Uh If you think that there might be a malignancy, uh something very important is to ask for estrogen risk factors. So, if there's anything that has increased estrogen levels, so earlier, uh first period, um nearly priority uh many pregnancies, breastfeeding or OTC or HRT all increase the risk for cysts and might increase the risk for breast cancer in some patients. So it's always important to have an appreciation of them in the history taking and then moving on to your normal history, very important in the drug history for the O BC and HRT uh past medical history. If they have anything uh any other problemss with their breast before family history, especially for breast and ovarian cancer, but any cancer is relevant and then normally social history in eyes. So before the examination, um explain why and what examination of the breast and underarm you will need to perform and what exposure you would need the patient to uh provide you with. Um So it's important to know that because many patients might not understand that they have to get undressed for a breast examination. They might think that they will have the breast examination over their shirt, for example. So that's important to explain that you, this is what you need to do. And the there is why that you need to have a closer look on the lump that they have. Um you need, you can also state in the rain force that you will having that you will be having a sapone. Um And that the examiner will be acting as a chaperone uh and then obtain consent to proceed with the examination at this stage. In order to show to the examiner that you are understanding the difficult position that the patient is in. Um you should pretend that you are leaving to allow the patient to undress even if it's a model because that shows that you are minimizing the exposure for the patient. Um And before you begin, the three things that are very important to ask for is a pain uh lumps and discharge. And if they reply positively to any of those, it's always a good. They ask the patient to point towards where those are. So show me where the pain is, show me where the lump is uh press on, press on where the discharge comes from. Um Because that's minimizing the invasiveness of your own technique, but also allowing all the patients uh to exactly the same case where the symptoms you are presenting with are. So for the breast examination, you will first for the first part, need the patient to be sitting upright and that follows the self-examination uh guidelines. So first like normally upright, have a general inspection. So say that you will be starting with a general infection from a distance, not the general size, symmetry and contour of the breasts. Any visible um microscopic skin and nipple changes and any other swellings in the general area around the breasts. Pale is a very useful pneumonic because it can help you note any um po arms, any skin changes, lumps invasion discharge. So very key things to cross out from just the general inspection. Um Then you will need to ask the patient to put their hands on their hips and hands. Um And when you say that you need to re to repeat the inspection, also look for any masses that become uh more pronounced with the PMA. Uh So this would be ones which are more likely to be malignant. And finally, you would need the patient to put their hands befo beho be behind their uh head um and ask them to lean forwards because that will allow you to appreciate any uh skin tingling. Then you would need to uh ask the patients to lay down on the couch, not completely, usually 45 degrees is fine. Um and GP so that you are repeating the inspection all around the breast and the axillary tissue. So make sure to go both sides um of the bed and look around the axil as well. Um And then so a systematic approach, uh it doesn't really matter which approach you choose to do, whether you wanna do a circular one. The concentric ones do the quarters as long as you show that you have appreciated every several, every distinct uh quarter, um, deep to superficial. Um And some, no doctors know that it might be a good idea to start palpating the asymptomatic breast to have an understanding of what normal feels. Um And it's a good idea to keep the other one covered at any given moment. So that again, you should be examined that you're minimizing exposure for the patient. Um After you complete the examination of the breast itself, you should examine the breast tissue which extends from the clavicle to the upper abdomen and the midline to the posterior axillary fold to show that you are understanding that it's much more than the breast issue that you're looking for. Um and also important the axillary tail, which is the one that's extending from the outer corner towards the axilla. Um and also for the nipple. Um It's a uh preferable that you ask the patient to do. So, even if it's a model, you might say um that please show me uh the discharge or please show me um if there's any discharge coming off because um it's showing again to the uh the examiner that you are um empathetic of the intimacy disc examination. And as a final step, uh you need to do uh a lymph node assessment. So you will need to fill for the lymph nodes. There are five sets of lymph nodes in the um brea around the breast as you can see in the diagram here. Um But beforehand, you need to ask for shoulder pain because you will need to um uh press on the auxilin if they have any shoulder pain that might make them uncomfortable. So always make sure to ask for any shoulder pain. Um And then uh tell them to relax. Um have the place your hand behind your head and some it behind so that you can have a closer look for any scars, any masses and any skin changes in the axillary fold, um followed by a full patient um with the opposite hand. So if you are looking at the right axilla, use your left hand, although that's not something very, very important. That's the standard way that's um um that most doctors follow with uh examining for lymph nodes and, and um you need to palpate, you might also name if you're asked the axillary lymph nodes. So those would be the PTU ones, the anterior ones, um the center, the central ones, the subscapular ones, the humeral ones and the apical ones. So it's a good idea to have a rhythm of them the night before the uh exams because that's something that as anatomical question they might ask you. And finally, um you need to uh uh tell the patient that you will now be moving on the back of the back so that you can appreciate clavi the nodes on the neck. Um And you need to have a look at the supraclavicular fossa um and also on their cervical chains, uh you would do another any other normal examination involving that. So from the heart systematically all the way from the clavicle up to the neck and below, uh and below and down below the front of the neck. So, as well as the breast itself, um during an examination of the breast, you should be examining the axillary tail, the axilla, the original lymph nodes around the area, the cervical chain and the supraclavicular fossa. So five things, five lymph nodes uh in the axilla that you should um uh think about and also five broad categories of pathologies in the breasts. So concluding the exam, um you need, you have to say that you are not concluding the exam and help the uh patient getting dressed. Uh Thank them and wash your hands. And for this examination, most likely you will either be uh asked to report back to the examiner or document the procedure and the finding in the notes. So whenever you're documenting or asked to document anything in the house case, make sure that you document what you did. Um the patient credentials, uh the S credentials and your own credentials, including your or your o and any findings that you've had, um whether you could do this in written or if you feed back back to the um examiner, um A summary of the examination would include the patient's name, uh age or date of birth, what they presented with. And then con considering every step of the examination, uh the positive findings alongside any important negative findings. So what you found on general inspection, closer inspection of the breast um and then common on specific aspects of the lump uh based on the six s um lymphadenopathy. Um and then a final statement on if that's a normal or not normal examination, what you would do or ask to be done after you complete your examination. And most importantly, for the two week wait, something that you might be asked or need to say is that whether that's um an examination that's um making you wanna refer to two week wait or not. And that should be justified based on the guidelines. And it's the guidelines are basically um depending on age, but also depending on uh the characteristics of the lump. So if you have any characteristics suggestive of malignancy, then you would uh refer for a two week weight. So that's um now if there's any questions, uh let me check in the group chat. Um If you have any questions, please volunteer them um before we do a final um diagnosis, please. Thank you, Aelia. Thank you. Um So if anybody hasn't filled out the feedback form yet, um it should be in the chart. I will rear it. If not, you can scan the QR code on the screen and thank you so much for joining. Thank you once again, Aal, thank you. Um And if you have any questions, feel free to contact me on my email and also any feedback you have, please fill in the feedback form.