Asking the patient about any breast changes including size change, dimpling, or nipple discharge would be helpful (Centers for Disease Control and Prevention, 2018). In addition, asking the patient about any family history of breast cancer and her menstrual cycle timing could be helpful. A breast exam would be appropriate during this patient’s physical exam. The patient reported feeling a lump in the shower. By the provider doing their own exam, the patient’s technique and lump placement could be verified (Centers for Disease Control and Prevention, 2018).
Some possible differential diagnosis for this patient include breast cancer, a cyst, fibroadenoma, lipoma, mastitis, and breast injury (Mayo Clinic, 2018). Getting a full health history and ordering tests would be needed to know for sure. Some tests that may be ordered include imaging to see what the potential lump looks like and placement. A mammogram is commonly used along with a biopsy to test the breast tissue cells to determine if they could be cancerous (Mayo Clinic, 2018).
Based on the results for this patient, it is possible that a referral could be necessary. This patient may need to see an oncologist or even a surgeon. If this patient has cancer, radiation or chemotherapy may be an necessary intervention (Mayo Clinic, 2018). Making sure this patient has access to information and support is also important when considering management of care.
Centers for Disease Control and Prevention. (2018). “What Are the Symptoms of Breast Cancer”. Retrieved from: (Links to an external site.)Links to an external site.https://www.cdc.gov/cancer/breast/basic_info/symptoms.htm
Mayo Clinic. (2018). Breast lumps. Retrieved from https://www.mayoclinic.org/symptoms/breast-lumps/basics/causes/sym-20050619 (Links to an external site.)Links to an external site.
A 35-y.o. woman is seen in the office with a chief complaint of a breast mass. She states she found the lump when she was in the shower, and she is quite visibly distressed. Her medical history is unremarkable, although she reports that she has not had a mammogram. She takes no prescription medications.
What additional questions should you ask the patient and why?
- Additional questions to ask this patient would be if the lump is painful, pain in fibrocystic disease is bilateral and increases before the monthly menstruation.
- Has the lump changed in size or remained the same, has she ever noticed a lump before, is she menstruating. Cyst gets smaller and pain decreases when the menstrual cycle starts. If the patient is menstruating it is important to have her come back at the end of her menstrual period. This is because the breast cysts can fluctuate during the menstrual cycle (So you found a lump, now what? 2015).
- Does she have a nipple discharge? A nipple discharge that is unilateral, pink or bloody, non-milky or associated with a mass is an indicator of breast cancer.
- Ask at what age did she begin menstruating because early menarche increases the risk of breast cancer.
- Does she have a family history of breast cancer? If a mother or sister had breast cancer there is twice the risk and if both have it there is three times the risk of developing breast cancer.
- Does she have any children? Null parity increases your risk of breast cancer (Seller, & Symons, 2018).
What should be included in the physical examination at this visit?
A complete breast exam should be included in this visit. The breast lump should be assessed to determine if it is firm, with indistinct borders and if it is attached to the skin. Assessment should include if there is any dimpling or nipple retraction, and unilateral nipple discharge, all of which are a signs of breast cancer. Benign lumps usually have well-defined borders and are mobile (Sellers, & Symons, 2018).
Possible differential diagnoses at this time are as follows:
- Breast cancer–Patients that develop breast cancer with no family history are normally older than 40 years.
- Fibrocystic breast disease-Patients have cyclic bilateral breast pain, especially near and during menstruation. The pain and tenderness worsen before menstruation.
- Fibroadenoma- Usually presents in patients 20-40 years. Usually, a solitary lump that is firm, mobile, smooth, and rubbery (Seller, & Symons, 2018).
What tests should you order and why?
A mammogram is the first test to order. If the mammogram is inconclusive or the breast has dense tissue then a breast ultrasound should be ordered to differentiate between a cystic mass and a solid mass. If needed a needle aspiration breast biopsy should be ordered. In some cases an MRI can be ordered, especially in high-risk patients (Sellers, & Symons, 2018).
How should this patient be managed?
If it is fibrocystic breast disease the patient should be advised to wear a firm bra even at night. Dietary restrictions will include coffee, chocolate, and tea. The patient should also take 400 IU of vitamin E daily. If the patient is experiencing pain or moderate to severe fibrocystic breast disease, the therapeutics to prescribe are oral contraceptives, NSAIDs and/or progestin. The patient should also be educated on the importance of conducting breast self-exams monthly even though the breasts may be lumpy (Dunphy, Winland-Brown, Porter, & Thomas, 2015).
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. A. (2015). Primary
care. The art and science of advanced practice nursing. (4th Ed.). Philadelphia, PA. F. A. Davis Company.
Seller, R. H., & Symons, A. B. (2018). Differential diagnosis of common complaints. (7th Ed.). Philadelphia, PA. Elsevier, Inc.