Intercostal Tube

Take consent. Provide adequate Privacy.
Ask her to be seated first.

1. Expose up to the waist. Use a cloth to cover the lower torso and a chaperon.
2. Ask the patient on which side the lump is and whether it is tender before you touch.
3. Look for breast asymmetry, skin changes (erythema, ulceration, peaud'orange appearance) and nipple changes (deviation, retraction, destruction).
4. Ask to raise both upper limbs and look for skin tethering. Don't forget to inspect the sub-mammary area.
5. Ask the patient herself to squeeze her nipple if she complains of a nipple discharge and check whether it is blood stained.

Then ask her to lie down and put her both arms behind her head.

1. First palpate the normal breast using the flat of the fingers. Then palpate "6 areas"; namely the four quadrants, subareolar area and axillary tail in order.
2. Then palpate the contralateral breast. Determine the site, size, shape, consistency, surface, regularity and the margins of the lump (if the lump is not palpable, ask the patient herself to locate it for you).
3. Check the skin attachment of the lump while in the supine position.

Then ask her to be seated again.

1. Look for deep structure attachment. Ask her to keep her ipsilateral hand on the hip and press against waist when she is asked to. Check whether there is a reduction in mobility when the Pectoralis Major muscle is contracted. Proper contraction of the muscle is confirmed by palpating the anterior axillary fold by the other hand of the examiner simultaneously.
2.  Assess both axillae. Ask the patient to rest her arm relaxed on top of yours as shown in the picture. Palpate all the axillary lymph node groups - anterior, lateral, medial, posterior, central and apical. Assess their consistency and mobility if palpable.
3. Finally palpate for supraclavicular lymphadenopathy.
4. Dress her up and thank her.

At the end of the examination, come to a clinical staging depending on your findings.

On inspection there is no breast asymmetry, tethering, any skin or nipple changes. She is having a lump in the upper outer quadrant of her right breast measuring about 3cm x 4cm x 4cm in size. It is hard in consistency, irregular in shape and margins are ill defined. It is not attached to the skin or the underlying muscles. There is a hard, mobile solitary lymph node in right axilla in the anterior group. Left breast and left axilla is clinically normal. My clinical staging is T2N1M, and would like to complete the triple assessment and proceed.

Consent. Privacy. Expose up to the waist.

1. Seated,

• Breast asymmetry, Skin changes and Nipple changes.
• Skin tethering & sub mammary area.
• Nipple discharge?

2. Supine & both arms behind the head,

• Normal breast first. Palpate 6 areas. 
• Determine the site, size, shape, consistency, surface, regularity and the margins of the lump.
• Skin attachment.

3. Seated again,

• Pectoralis Major attachment. 
• Assess both axillae & Supraclavicular lymphadenopathy. 
• Dress her up.

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1. What are the Indications to insert an IC tube?

1. Drainage of haemothorax, 
2. Drainage of Empyema (Pyothorax).
3. Drainage of large pneumothorax.
4. Drainage of large pleural effusion.
5. Flail chest/pulmonary contusion requiring ventilator support. 
6. Prophylactically in a patient with chest trauma before transportation.

2. How would you investigate this patient?

Triple assessment should be done. To complete it,
1. FNAC/True cut biopsy.

2. USS/Mammography of both breasts.

3. If FNAC confirms it is a malignancy, do you still want to do imaging?

Yes. It must be done to exclude multifocality and to detect impalpable lesions in the contralateral breast.

4. What are the mammographic features of a breast CA?

1. Structural distortion.

2. Spiculated lesions.

3. Microcalcifications.

5. How do you stage breast CA?

TNM staging. 

1. T staging

1. <2cm.

2. 2-5cm.

3. >5cm.

4. Any size lump.

a. Attached to chest wall.

b. Attached to skin.

c. Attached to both.

d. Inflammatory breast CA.

2. N staging

0. No Lymph nodes. 

1. Mobile ipsilateral axillary nodes.

2. Fixed ipsilateral axillary nodes.

3. Ipsilateral supraclavicular/ internal mammary nodes.

3. M staging.

MX - Unknown Mets.

MO- No Mets.

M1 - Metastatic Breast CA

6. What are the contraindications for breast conservative therapy?

1. Multifocality.
2. Pregnancy.

3. Extensive diffuse microcalcifications.
4. >5 cm or large relative to the breast size.
5. Poorly differentiated CA.
6. Any contraindications to radiotherapy.

7. How do you manage the breast CA?

1. Surgery (Conservative/simple mastectomy).
2. Radiotherapy.
3. Chemotherapy (Doxorubicin). 

4. Hormonal (Tamoxifen in young, Aromatase inhibitors in elderly).
5. Biologics (Tratuzumab for HER2+ breast CA).

8. How do you manage the axilla?

1. Sentinel node biopsy.
2. Axillary node sampling.
3. Axillary clearance (Level of axillary clearance depends on the extent of the tumour spread. E.g: Level II or Level III axillary clearance - usually level II).

9. How do you manage a histologically confirmed fibroadenoma?

Reassure if <4cm and <25 years of age, but 3 monthly assessments are needed (which is difficult in most clinical setups).