Week 5 response 2

Table 1

Definition Presentation/ Sign and Symptoms

Management

Mastalgia

Pain or discomfort in one or both breasts classified as cyclic (associated with menstrual cycle) or non-cyclic (unrelated to the menstrual cycle) (UpToDate, 2025).

Dependent on the cause: cysts, stretching of cooper’s ligament, mastitis, inflammatory breast cancer, or ductal ectasia for example (UpToDate, 2025).

Dependent on the cause: simple cyst requires no intervention; complicated and complex cysts must undergo further testing and confirmation; Ductal ectasia is self-limiting but may resolve and leave a subareolar nodule; Mastitis is an infection and usually resolves with antibiotic, I&D, or needle aspiration may be required; Stretching of Coopers ligament requires structural support; Breast cancer will be referred to oncology for determination of applicable treatment (UpToDate, 2025).

Mastitis

Infection of the breast typically caused by staphylococci, enterococci, anaerobic streptococci, Bacteroides, or Proteus; can be lactational or non- lactational (UpToDate 2025).

Inflammation, pain, warmth to the touch, abscess formation, or ductal damage if lactational (UpToDate 2025).

Usually resolves with antibiotics which typically include Augmentin 875mg q12, Cephalexin 500mg qid , or metronidazole 500mg tid as the most common; treatment duration is typically 5 to 7 days but may be extended to 10 to 14 days if needed (UpToDate 2025).

Nipple Discharge

Classified as physiologic or pathological and is the third most common breast complaint; most cases are benign but can have an underlying cause such as papilloma (growth of the lining of the breast duct), galactorrhea; lesion, or malignancy (UpToDate, 2025).

White or clear discharge is considered normal and benign; unilateral discharge, bloody discharge, discharge associated with a new mass or lesion, color other than white or clear (UpToDate, 2025).

Dependent on the classification: physiological (galactorrhea) = treat the underlying cause (i.e. pituitary tumor, medication induced such as with SSRIs, endocrine disorders, or other medical conditions) (UpToDate, 2025).

Table 2

Breast Mass

A nodule or growth of tissue that represents an aggregation of coherent material; may be benign or malignant, solid or cystic (UpToDate, 2025).

Usually discovered incidentally r/t patient c/o pain, nipple discharge, or breast trauma; obvious or subtle, soft, firm, or hard; mobile or fixed; well-defined or non- discreet margins; may be accompanied by breast or nipple changes (i.e., ecchymosis, erythema, peau d'orange, or skin dimpling (UpToDate, 2025).

Dependent on the cause, the patient’s history, lab and imaging results, and clinical findings (UpToDate, 2025).

Nipple Changes

Changes to the appearance, structure or function of the nipple classified as either physiological or pathological in nature (UpToDate, 2025).

New onset inversion of the nipple, presence of nipple discharge, nipple ulceration such as in Paget disease, nipple enlargement (UpToDate, 2025).

Treatment of underlying cause (i.e., infection = antibiotics; new onset nipple inversion = no treatment necessary; nipple ulceration such as in Paget disease = biopsy & referral to oncology; nipple enlargement = usually r/t menstrual cycle and will self-resolve) (UpToDate, 2025).

Diagnostic test How is this test helpful in breast conditions

Natalie is a 31-year-old G0 P0 female who complains of intermittent breast pain. She thinks she feels lumps in the outer quadrants of her breasts but is unsure of the location today. She has no family or personal history of cancers, she menstruates regularly, is not pregnant, and uses condoms consistently for BCM and STI protection.

1. Subjective: a. What other relevant questions should you ask regarding the HPI?

Do you notice the breast pain during your menstrual cycle or at random?

Do you notice the lumps around the time of your menses or at random?

Can you point to the exact location of the pain?

Can you point to the exact location of the lumps when you feel them?

Screening Mammogram

Regular breast screening can detect cancer at its early stages where it is more likely to be curable. Screening can also detect non-cancerous problems ensuring early treatment before the problem can progress (Mammography and Other Screening Tests for Breast Problems, n.d.).

Diagnostic Mammogram

Evaluates specific patient complaints including pain, abnormal skin or nipple changes, and discharge to determine the underlying cause for determination of appropriate treatment.

Breast Ultrasound Used in the monitoring of pregnancy and to monitor/diagnose other medical conditions based on patient complaints (Ultrasound Exams, n.d.).

MRI of the Breast Used for breast cancer detection in high-risk patients, evaluation of silicone implant integrity for early detection and treatment as necessary (UpToDate, 2025).

Biopsy (FNA and CNB)

FNA (fine needle aspiration) & CNB (core needle biopsy); FNA can provide rapid confirmation of a suspected malignancy and may potentially expedite planning for treatment and clinical trials; the downside to FNA is the tendency for false positive results; CNB is the preferred initial method as it is less invasive and is reliable if adequate tissue has been obtained; both methods are used for the assessment of cancer (UpToDate, 2025).

Surgical Biopsy

Not the first method but is utilized when needle biopsy is not feasible; this method is able to excise the entire lesion for analysis; may be indicated if aspiration does not completely resolve a cyst (UpToDate, 2025).

How long does the pain usually last?

Does the pain interfere with your sleep or any daily activities?

Can you describe the characteristics of the pain?

Can you describe the characteristics of the lumps when you feel them? Do they feel soft, solid, hard, mobile, fixed in place, tender?

Are the lumps associated with other symptoms such as redness or warmth to the touch?

Are your breast changes associated with any other symptoms such as nipple discharge? If so, please describe color, odor, consistency.

Any fever or chills when the pain or lumps are present?

Have you tried anything OTC for relief of the pain? If so, what have you tried? How effective was it? Did it relieve your pain partially or completely? How frequently did you need to administer the chosen method?

Have you sought evaluation and treatment for this at another location? If so, what was the outcome? What was the diagnosis?

Do you wear a bra with adequate support daily?

1. What other medical history questions should you ask?

Do you have any chronic medical conditions for which you are being treated?

What medications do you take at home if any? Please include any OTC supplements/herbs.

1. What other social history questions should you ask?

Do you currently, or have you ever engaged in smoking, vaping, illicit drug use, or alcohol? If so, how much?, How often?

Do you exercise? If so, how often, how much?, what method?

How would you describe your eating habits? Do you drink enough water throughout the day?

HPI: 31-year-old G0 P0 female who complains of intermittent breast pain. She thinks she feels lumps in the outer quadrants of her breasts but is unsure of the location today. She has no family or personal history of cancers, she menstruates regularly, is not pregnant, and uses condoms consistently for BCM and STI protection. States she does not like to wear bras as they feel confining. Patient reports 5/10 (at the highest) pain level when the pain is present and affects both breasts equally. Points to the 3 o’clock and the 5 o’clock locations to the right breast, and

the 1 o’clock and 4 o’clock locations on the left breast. Reports the pain and the lumps are present at the same time and has not noted whether or not it is around her menstrual cycle or not. Reports this is new and has not sought care before today. Reports the lumps feel “soft and squishy” and are not painful. States she is not comfortable taking pain medication and fears side effects of medications in general. Denies any fever or chills and any other breast changes. Reports she does get regular exercise at the gym 4 to 5 days a week with friends and reports a healthy high protein diet with an occasional cheat day. Reports she has never tried smoking, drugs, or alcohol but her mother is a smoker.

Subjective:

General: Denies malaise, weakness, fever, or chills.

Cardiovascular: Denies chest pain or discomfort, heaviness, or tightness; denies palpitations, SOB, or swelling to the hands or feet.

Respiratory: Denies cough, wheezing, congestion, SOB, recent illness, or travel.

Skin/Breasts: Denies rash, itching, redness, or other skin changes; reports breast pain 3/10 to both breasts in general; reports lumps to the outer portion of both breast with no pain or tenderness unless pressed; denies pain or discharge to the nipples bilaterally.

Objective:

Vital Signs: 97.6, 77, 18, 126/78, 99% RA, 3/10 pain

Constitutional: Vital signs WNL, no acute distress noted, breathing even and unlabored, alert & oriented x 4, well appearing.

Cardiovascular: S1, S2 heard, no murmurs, rubs, or gallops noted

Respiratory: Lung sounds CTA bilaterally

Breasts: Skin intact with no lesions, masses, or rashes noted; mild tenderness to palpation to the outer breast bilaterally at approx 3 o’clock and 5 o’clock, normal breast tissue noted; no nipple discharge or pain; normal appearing breast bilaterally.

Integumentary: Skin warm, dry, and intact; no lesions, masses, rashes, or discoloration.

Assessment/ Diagnosis:

Working Diagnosis: Cyclic Mastalgia (ICD 10: N64.4) Vs. Non-cyclic Mastalgia ICD (ICD 10: N64.59) Vs. Unspecified superficial injuries of breast, unspecified breast, initial encounter (ICD 10: S20.109A).

The patient is experiencing intermittent breast pain and lumps to the outer portion of the breast bilaterally. However, she is unable to confirm whether or not these symptoms are associated with her menstrual cycle which would make a difference in terms of work-up and treatment. There is an absence of more concerning complaints such as nipple changes/discharge, breast changes, and s/s of infection. The patient is also denying any personal or family history of breast cancer, medical conditions, or medications that may contribute. Patient also reports she does not wear bras due to feeling confined. For these reasons, I am only considering cyclic versus non-cyclic Mastalgia versus possible cooper ligament injury.

Plan:

US of bilateral breast ordered (evaluation of breast tissue); if inconclusive, will order mammogram.

Tylenol 650mg PO QID PRN for pain relief

Educated patient regarding the risks and benefits surrounding utilization of a bra for adequate support due to the suspicion of injury to the Cooper ligaments of the breasts.

Keep a log of when the pain/lumps are felt, the characteristics, and note status of menses.

Further treatment considerations pending US results

RTC in 2 weeks to discuss US results and follow up on current status of pain and lumps to the breast.