---

HISTORY OF PRESENT ILLNESS (HOPI)

Chief Complaint: Right Breast Lump

---

1. PRESENTING COMPLAINT

---

2. HISTORY OF PRESENTING COMPLAINT

(A) The Lump

S Das key point: "A lump with a long history and slow growth is a benign condition — either fibroadenosis or fibroadenoma. A lump with a short history and fast growth is probably a carcinoma. The average duration between the patient finding the lump and reporting it to a surgeon is about 6 weeks in case of carcinoma."

---

(B) Pain

• Presence or absence — Carcinoma of the breast is classically painless. A painless lump accidentally found during washing must raise suspicion for malignancy.
• Character of pain — Throbbing pain → pus formation (acute mastitis); Cyclical pain aggravated with menstruation → fibroadenosis.
• Radiation — Pain at the back, hip, or shoulder in long-standing cases → possible bony metastasis (often mistaken by patient as rheumatism).

"All neoplasms of the breast — either benign or malignant including carcinoma — are painless to start with." — S Das

---

(C) Nipple Discharge

• Present or absent?
• Type of discharge:
  • Fresh blood / altered blood → duct papilloma or carcinoma
  • Pus → mammary abscess
  • Milk → lactation, galactocele, mammary fistula (chronic subareolar abscess)
  • Serous / greenish → fibroadenosis or mammary duct ectasia

---

(D) Nipple Retraction

• Recent onset → highly significant — suggests underlying carcinoma
• Since puberty / long-standing → likely developmental/congenital
• Recurrence of abscess may occur with congenital nipple retraction

---

(E) Skin Changes over the Breast

• Dimpling / puckering of skin (Peau d'orange — carcinoma)
• Redness, warmth, oedema → acute mastitis
• Ulceration over lump

---

(F) Systemic Symptoms

• Weight loss — suggests carcinoma or tuberculosis of the breast
• Loss of appetite, easy fatiguability — features of malignancy
• Bone pain (back, hip, shoulder) — bony metastasis
• Breathlessness / cough → pulmonary metastasis

---

3. MENSTRUAL HISTORY

• Age of menarche
• Regularity of cycles
• Any relation of lump/pain to menstrual cycle
• Menopausal status — post-menopausal lump has higher risk of malignancy

---

4. OBSTETRIC & LACTATIONAL HISTORY

• Parity (nulliparous women → higher risk of fibroadenosis and carcinoma)
• History of breast feeding (protective against carcinoma)
• Currently lactating? (Acute mastitis / lactational abscess common in first lactation)

---

5. PAST HISTORY

• Similar lump in past (treated / untreated)?
• History of breast abscess, TB breast, previous breast surgeries
• Carcinoma may recur in the opposite breast — ask about any prior diagnosis/treatment
• H/o radiation exposure to chest

---

6. PERSONAL HISTORY

• Marital status — fibroadenosis and carcinoma more common in unmarried/nulliparous women
• Dietary habits — diet rich in saturated fatty acids linked to breast carcinoma
• H/o oral contraceptive pill use or HRT (hormonal risk factors)

---

7. FAMILY HISTORY

"Majority of breast diseases including carcinoma often recur in a family." — S Das

• H/o breast carcinoma in mother, grandmother, sister, or other first-degree relatives
• H/o ovarian carcinoma in family (BRCA1/2 association)

---

8. SUMMARY STATEMENT (for case sheet)

"Mrs. _______, a ___-year-old [marital status] female, para ___, presented with a painless / painful lump in the right breast since ___ months/weeks, which she noticed accidentally while bathing / due to pain. The lump has been gradually / rapidly increasing in size. There is/is no associated nipple discharge, nipple retraction, or skin changes. She has/has no history of weight loss or bone pain. Her menstrual history is ___. Family history of breast disease is present/absent."

---

---

Quick Differential Diagnosis Guide (Based on History)

---

---

What's inside the case sheet: