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I can hear me. Just put a yes in the chart if you can get me. Can you hear me? OK, cool, fine. OK. Um We'll get started then. So, hi, my name is Pavia. I'm one of the fifth years at Manchester. Um I'm just hosting the teaching session today, so I'll just be in the background, monitoring the chat and things like that. Um Today, we've got the first half of the session on breast teaching. Um and that'll be done by Shivani and then the second half is gonna be oy practice. So do try and stick around for that because it is really useful. Um But yeah, I'll have over tissue money. Perfect. Thanks PAA. Um So hi everyone. My name is Vani. I'm a final year at Kings. Um And we're going to be looking a bit at uh breast history taking and um to equate and some conversations. So just a disclaimer, this doesn't replace any formal teaching and these are some of the partners. Um So yes, so like I mentioned today, we'll be covering um general his history, history taking um and tailoring it to a breast, presenting complaint, looking at the most common breast lump differentials, the most common um nipple discharge differentials looking a bit at the two week wait and what an OS station would look like. Um looking at the National screening program for breast cancer and applying that to a communication station. Um and oh II, don't go through the breast exam. Sorry, that's scenario. Um So about the breast history taking. So the first part of, of the sort of the structure is very similar. So you've got your presenting complaint, your history of presenting complaint, and you go through all of that. I'm not gonna um go through the details. I'm pretty sure you, you're all very familiar. Um But there is an emphasis in breast history taking on the family history, especially if the patient that you're talking to is young or the patient is male. Um So you want to ask if there's a family history of cancer, but also ovarian cancer because of the BRCA one and BRCA two genes. And then also we want to ask at what age um these family members were diagnosed because if they were diagnosed at younger age, then it's more likely to be a genetic um component to their malignancy. And then if the patient that's come to you um is female, then you want to ask a bit about the uh past um obstetric and gyne history as well. So when we are talking about breast history, um there are certain um specific things we want to ask about. So the most common one would be a lump that um that sort of patients will come in with and you want to Socrates, that lump. So you, so Ocrates is site. So you ask them to describe where it is, you can even ask them to point um of onset. So when did they first noticed it um characteristics? Whether when they feel the lump, does it feel so smooth, irregular? Does it move around? And is there pain? Um then after radiation, if there is pain, does it spread anywhere else associated symptoms? So you'd ask about all the other things that I've listed here. So any nipple discharge, any skin changes, any bee symptoms, any lymphadenopathy, um the time course. So if there is a lump, has it changed in size? And does it, or does it change with the menstrual cycle? Um if they've noticed that e so exacerbating or relieving factor, was there any preceding trial? If there is pain, does anything make the pain better or worse? And then as the severity. So if there is pain, ask them to rate the pain and then about nipple symptoms, you want to ask about nipple discharge, um bleeding and inversion. So about the discharge, you want to ask about what the color of the discharge is, how much discharge is coming out, whether it's spontaneous or not. So that is whether if uh um or whether if it comes without having to press the nipple or does it only come when pressing the nipple and whether it's coming from one duct or multiple? But that's probably something that you would visual examination while the patient tell me that and then ask about any skin changes in particular, we're looking at any sort of eczema, um sort of an eczema type, dry skin changes any skin retraction and then ask if there's uh if they've noticed any asymmetry in the sizes of their breasts, any pain in the breast, if there is pain, is it bilateral or unilateral and then any lumps in the neck or axilla, which could uh possib possibly be lymphadenopathy and then any bee symptoms, those are like your classic red flag symptoms you want to always ask about. So, fever, weight loss, night sweats. So, um the symptoms listed here that are sort of your red flags are the ones in red. So, a lump um in skin retraction, asymmetry of the breasts and any lymphadenopathy. And then these symptoms. So just to straight what nipple inversion looks like. So there are grades of nipple inversion. So um a protruding nipple is normal. So this is when it's not inverted. Grade one nipple inversion is when it can be easily pulled out and it will stay out. Grade two nipple inversion is when it can be pulled out. Um But then once you let go, it retracts back and then grade three nipple inversion is where you can't pull it even with pressure. So we're gonna look at a few differentials of breast lumps. So the first one is fibroadenoma. So this is a benign tumor and it arises from the terminal duct lobule stroma in the breasts. Usually it's between, um you see, it's seen in 20 to 40 year olds um amongst women of reproductive age, the exact cause isn't really known, but it's thought to be due to hormonal factors if see, of breast tissue to estrogen. And it's very, very rare amongst men that you see fibroadenomas, they're also known as the breast mouse um because they move around a lot within the breast tissue um because they're responsive to hormones, that's why they're more common in younger women and then they often regress after menopause. So you mostly see them premen premenopausal women during pregnancy. And then whilst using the combined pill, sometimes that patients would usually complain about they could be asymptomatic. But if they feel the breast lump, the breast lump would be painless, it would be mobile, it sort of move around, it will feel smooth, round, um well circumscribed and it, it's usually just one that they would feel and it will be around 2 to 3 centimeters in diameter. And the classical presentation that um that you'll get in a progress test question as well would be it's in the upper outer of the breast. So the next one is a breast cyst. So this is filled with fluid and it's due to the overgrowth of sort of the glandular tissue and the connective tissue in the breast. And because of this overgrowth, it leads to the blockage of the ducts in the breast. And so the fluid tends to then accumulate. And um there could be multiple cysts or you can just have a low cyst um on its own. And you typically see this in women between 30 to 50 years old. So again, they can, they can be asymptomatic. They can't really feel the if they can't feel the lump, otherwise, if they do feel it, then it will feel smooth, well circumscribed M LTU. So this is where it feels like a, it feels like a grape and it feels like there's fluid inside. So the next is fibrocystic breast changes. So this was previously called fibrocystic breast disease. But um it sort of um the term is used because it's considered a variation of normal and not really a disease. So it's refers to the general um lumpiness of the breast. So the connective tissue in the breast, the ducts and the lobules of the breast, they all respond to um estrogen and progesterone. And uh so they become fibrous, they can become fibrous um and they can become cystic. So, fibrous means it can feel quite irregular and hard cystic means it becomes fluid filled. Um and these changes tend to fluctuate with the menstrual cycle. So it's, it's a benign condition, it's not cancerous, but it can vary in severity and can really affect patients quality of life if it's really severe. Um So it's most common amongst women of menstruating age and symptoms often um sort of develop prior to menstruating um and then resolve once menstruation begins. Um and then usually the symptoms sort of improve or resolve after menopause. So again, so the symptoms that you get would be breast lump, um they also complain of pain and tenderness and then you can get fluctuation of breast size with the menstrual cycle. Um on um on imaging, they, there, there can be um this can cause sort of mammographic changes which can mimic carcinoma. Um but with sort of expert opinions on, on the image that's obtained, um they can rule that out. All right. So, next one is a lipoma. This is a sort of benign uh mass of the adipose tissue. It can occur anywhere in the body really. Um And they very rarely undergo malignant transformation to become liposarcomas. Um So again, the symptoms are that you'll get a breast lump. Um it will soft, smooth, painless mobile with no sort of skin changes around it, but I think you do need to monitor it um in case um in the odd chance it does develop into a liposarcoma. Next one is fat necrosis. So, um this is when there's sort of localized degeneration of the fat tissue in the breast. So, it's usually the typical question that you'd get in like, um, a written exam as well, uh, or in the history that you'll obtain is that there was some trauma to, to the region. Um, but it, um, other triggers can also be radiotherapy and surgery. And so consequently, what happens is the inflammatory reaction to that trauma or the radiation of say is that you get fibrosis of that area and then necrosis as well. So the symptoms that you get are um, you can have a painless lump that feels quite firm, irregular, it's fixed to the local structures because it's sort of within the fat tissue of the breast. And then they, there can be um skin dimpling or nipple inversion as well and then onto a galactal. So this is also called a milk cyst and it's pretty much exclusively seen in lactating women and it's essentially due to obstruction of the ducts in the breast during lactation. Um So what patients would uh sort of complain about again is a lump that feels firm, mobile, painless. Um And it's usually sort of around the areola region. So what do you guys think if you wanna put in the chart, what you guys think the investigations would be for all of, um, sort of presentations or conditions? Yeah. Yeah, exactly. So, based on, based on just clinical examination and uh history taking, um you can't really distinguish between a carcinoma, um, fat necrosis or lipoma. So, you would do, you would refer them for a two week wait. Um, that depend on certain criteria. They have to be above a certain age, but we'll go through those period later. Um All right. And we'll go through what, um, what the triple assessment entails as well. So we'll just go through some um differentials of nipple discharge. So, the first one is mammary duct, ectasia. So this is where you get sort of dilation of the large ducts in the breast. Um and it usually happens in perimenopausal women. Um and a major risk factor that you'd see in sort of your written exams as well is smoking. So what essentially happens is there's inflammation of the ducts and that essentially um you get a sort of intermittent discharge because of the inflammation as inflammation sort of brings with the edema. Um and um and so you can get discharge from uh the nipple. So usually patients would complain about a nipple discharge, they look sort of white or gray or green. Um it can be tender um and they can also have nipple um inversion. Um And if it's quite, if the inflammation's quite sort of prominent and you and um a lump is palpable, then sort of pressing on the lump may produce the, the, the the discharge from the nipple. So in terms of what you would do for investigation. So again, for anything that's concerning, especially in a woman that's over 30 you would want to refer for triple assessment. Um But then once you um you sort of ruled out any sort of a anything sinister going on like a carcinoma, then you can also do other investigations. So, ductography is wherein you sort of inject contrast into the abnormal mammary duct. And then um you image that using a mammogram to visualize that duct that's got the contrasting, then you can do nipple discharge cytology. So that's essentially examining the cells in the sample of the nipple discharge. And then ductoscopy, which is inserting a very tiny um endoscope into the duct to sort of visualize what's going on. So the management, once um cancer is ruled out, you can reassure the patient and you um what generally tends to happen is you, you, you just observe and then if there's any pain and then you can advise that they take nsaids if there's any concurrent infection that they can take antibiotics. So the next one is duct papilloma. So essentially this is due to um proliferation of the epithelium in the ducts. So again, it's to do with the ducts. Um it's benign, but it can be associated with um with sort of a malignancy. The symptoms that patients generally complain about are clear, um clear discharge or blood stained discharge. Um and it's usually come, it usually comes from one duct because the growth is only in one duct. Um it can be painful. And then again, if um if the growth is quite big, then you then there can be a palpable lump. So again, uh investigations rule out anything sinister. So you would do a triple assessment for anyone with a nipple discharge just to rule it out. And then again, you can do so you have the contrast. Um you take a mammogram to visualize it and then the papilloma, you can see it as an area that doesn't fill with contrast because it's blocking, it's blocking the duct. So there's a filling defect. And then the management for a ductal papilloma is you would um is you would excise, um you would excise the growth because it can be, there's a rare association with um malignancy. All right. So, onset mastitis. So this is essentially inflammation of the breast tissue. There can be a concurrent infection as well. The sort of major risk factor is breastfeeding. So what happens is there was, there's um there can be obstruction in the ducts um in the breast. And so the milk sort of accumulates um the milk can't be expressed as frequently. Um And then you sort of get that um that build up of the milk and uh subsequent inflammation, there can be um infection that happens as well because bacteria can enter the nipple and backtrack into the ducts. So the symptoms that uh women would complain about would be pain in the breast sort of focal redness um of the overlying skin warmth. Um which is sort of the general sign of inflammation, nipple discharge. Um If it's really quite bad, then they can be systemically unwell and have a fever and then you can see some skin changes as well such as dimpling or puckering of the skin. So the management um if it's um in a breastfeeding woman, then you would advise them to continue breastfeeding because if they don't, that milk is, is gonna accumulate more and that's gonna just make the symptoms worse. So you try and encourage expressing the milk. Um and then you can offer analgesia and warm compressors for sort of symptomatic relief. And then if they're systemically unwell, if there's a fissure um of the nipple, if symptoms haven't improved with sort of 24 hours of uh of efficient and effective milk expression, or if any cultures that you've done indicate infection, then you would start antibiotics. So it's so it's an antibiotic um that would cover for sort of the main um the main organism. So it's usually staph aureus. So you'd start them on a flucloxacillin or something. So if, if mastosis is left untreated, then that, that can develop into an abscess and then that would require um incision and drainage. So, an abscess. Uh so it's a complication, risk factors for infective mastitis slash an abscess are smoking. So, smoking is a really big one for infection. It also um it also very much delays the process of healing. Um If there's any damage to the nipples or eczema of the skin. Um any uh any piercings that the patient has, there's any underlying breast conditions and then immunosuppression and diabetes as well. So, the most common organism is staph aureus, but to get some anaerobes, um some strep, um some strep species and then enterococcus as well. So what patients would complain about the nipple changes, purulence, nipple discharge. So it will look quite pussy, um localized pain in the area of the abscess, it will be quite tender to touch, it, feel quite, quite warm or hot, it will look uh red, there could be hardening of the skin and breast tissue. Um So sort of if you've got an abscess anywhere, sort of the, the underlying tissue feels hard. Um and then they can be quite systemically unwell, so they can have myalgia, fatigue fever. So, with anyone that sort of um got this infection and if they're systemically unwell, you'd wanna do some bloods. Um and think about doing cultures if the, if you think that they look a bit septic, um do a pregnancy test if they're non breastfeeding um image to rule out any carcinoma, if there are any other associated symptoms that are worrying, and then you'd want um sort of input for microbiology. Uh So you want to culture the um the abscess after you drain it to inform antibiotic choice. So management, you would refer to the on call surgical team, you would want to do ultrasound, you wanna um incise and drain and you want to do a culture of the drain fluid. Um And then there's a different approach depending on whether the abscess is in a breastfeeding woman or a non breastfeeding woman. So, if it's lactational um mastitis or a lactational breast abscess, then you'd give flucloxacillin cos that's probably the most common organism. But if it's nonlactational antibiotic, that's really rare. And so you would be worried that sort of something else has happened and sort of an atypical um pathogen has sort of caused the abscess. And so you'd wanna give something more broad spectrum. So you'd either give them coamoxiclav or if they are allergic to penicillin, then you would give them a macrolide and metroNIDAZOLE. So the metroNIDAZOLE is to cover for the anaerobes. Um But then again, you would still advise to continue breastfeeding and expressing milk because the stagnant milk um and the accumulation isn't gonna help. All right. So, galactorrhea. So this is when milk, when breast milk is produced, not during pregnant or not associated with pregnancy in the postpartum period. And it's essentially in response to a raise prolactin. So here to remind you about what sort of feedback mechanisms control the release of prolactin. So, lactin is produced in the anterior pituitary and it's dopamine that comes from um from higher up that blocks the secretion of prolactin. So, dopamine agonists, uh sorry, dopamine antagonists. So, antipsychotic medications they usually result in raised prolactin and can result in galactorrhea. Um, dopamine agonists um are then used to suppress to suppress prolactin secretion. So it is usually used in the management of uria. Um, there are some endocrine disorders that can lead to hyper hyperprolactinemia. So, hypothyroidism and um, polycystic Ovarian syndrome as well. And then, like I said, medications, uh like antipsychotics can um decrease the dopamine levels and thus increase prolactin levels. So, investigations, you'd want to do a serum prolactin. Look at us LFT ST FT S. This is to get the bigger picture to see if there's anything endocrine going on. Um And then in terms of management, you would give a dopamine agonist. So because dopamine inhibits prolactin release. If you give more dopamine, you're gonna suppress the prolactin. So, um, bromocriptin and Agin are um the options available if you have done imaging. Um So if there's sort of any associated symptoms that may make you think that it's a prolactinoma that's there such as bitemporal hemianopia. And you've done an MRI and it shows that there's a prolactinoma. Um and sort of the size isn't