Week 5 student reply

Samantha

· Chief Complaint: small lump on  right breast

· History of Present Illness:  Madeline is a 41-year-old female who complains of a small lump she feels in her right breast. 

 What other relevant questions should you ask regarding the HPI?

· When did you first notice the lump?

· Has the lump been present for days, weeks, or months?

· Any change in size or shape over time?

· Do you feel any other lumps or abnormalities in either breast or underarms?

· Have you noticed pain in the breast or lump area?

· Any skin changes (e.g., dimpling, redness, warmth, thickening)?

· Any nipple discharge such as bloody, clear, or milky?

· Any changes in nipple position, inversion or retraction?

· Is the lump associated with your menstrual cycle?

· Any unexplained weight loss fever or chills fatigue or night sweats?

 

· Medications: What medications are you taking?

· Allergies/Immunizations: Any allergies? reports up to date with immunizations. Have you been vaccinated by HPV? 

· LMP: LMP date?

· GYN/OB History: 

· Have you been pregnant? If so, at what age was your first full-term pregnancy?

· Last PAP?

· Last Mammogram? normal/abnormal result?

· Menarche: At what age? 

· Are you on hormone replacement therapy, oral contraceptives, or other medications?

2. What other medical history questions should you ask?

· Are you on hormone replacement therapy, oral contraceptives, or other medications?

· Have you been diagnosed with any type of cancer before (especially breast, ovarian, or uterine cancer)?

· Are your periods usually regular?

· Past Med. Hx (PMH): Tell me about your medical history. Have you had breast lumps, biopsies, or previous breast cancer?

· Surgical History: Tell me about your surgical history

· Family Hx: What is your family history? Does anyone in your family (maternal or paternal) have a history of breast, ovarian, or other cancers?

· Are you taking any medications or supplements, including over-the-counter or herbal remedies?

3. What other social history questions should you ask?

· Social Hx: 

· Do you smoke, drink alcohol, or use recreational Drugs?

· Are you in a relationship? Do you feel safe?

· Are you sleeping well? Have you been feeling stressed or overwhelmed recently?

· How much do you exercise a week?

· Who lives with you at home?

· Are you currently sexually active?

· What is your occupation?

· Are you up to date with other screenings, such as Pap smears or colonoscopies?

· Do you experience high levels of stress or anxiety?

· Do you have a support system (e.g., friends, family) to rely on?

· Review of Systems (ROS):

· Constitutional: denies fever, night sweats, chills, fatigue, cold intolerance, weight gain, weight loss. 

· Respiratory: denies dyspnea, cough 

· Cardiovascular: denies chest pain or palpitations 

· Gastrointestinal: denies abdominal pain, nausea, vomiting

· SKIN:Any changes in the skin of the breast, such as redness, dimpling, or thickening?

· Breast: Any changes in the skin of the breast, such as redness, dimpling, or thickening? Any rashes or itching elsewhere on the body? Any rashes or itching elsewhere on the body?

· Lymphatic: Any swelling or lumps in the armpit or neck?

· Psychiatric: denies anxiety,  increased stress, depression, and suicidal ideation.

Objective 

Write a detailed focused physical assessment on this patient

· Vital signs: BP, HR, Temp, Ht, Wt,  BMI, SpO2, RR

· GEN: Vital signs stable, in no acute distress. Alert, well developed, well nourished. 

· RESP: Lungs clear to auscultation bilaterally, no abnormal sounds bilaterally, no use of accessory of muscles of respiration, nonlabored breathing, normal rate and rhythm, no shortness of breath, chest rise is equal and symmetric

· CV: S1, S2 without murmurs, rubs, or gallops appreciated.  

· Breast: approximately 2x2 cm firm, non-tender, immobile mass in the right upper outer quadrant of the right breast at approximately 10 o’clock, 1 cm above the areola palpated, no dimpling or discharge noted. Both breasts are symmetric in size and shape. No obvious abnormalities in the skin texture. No visible skin changes such as dimpling, redness, or puckering. No nipple discharge (clear, bloody, or milky) and no signs of retraction or inversion

· LYMPH: No palpable lymph nodes in the axillae, both right and left.

· Fetal Heart Tones: Assess if within normal range (e.g., 140 bpm if measured).

· INTEGUMENTARY: Skin was warm and intact. No rashes, masses or discoloration. No trauma. 

· EXT: No cyanosis/ edema/ clubbing. Pulses +2 bilaterally radial and pedal.

· PSYCH: A&O x3 judgment/insight intact, NL mood/affect. Judgment and insight were within normal limits at the time of the visit.  

Explain what test(s) you will order and perform, and discuss your rationale for ordering and performing each test.

· POCT: 

· Urine or Serum hCG: Pregnancy test should be considered if there is any possibility of pregnancy. This is particularly important if the breast lump could be related to pregnancy or breastfeeding, as pregnancy can alter breast tissue, and certain treatments or interventions for breast lumps may be contraindicated during pregnancy

Assessment (Diagnosis/ICD10 Code) 

What is your diagnosis?

· Working Diagnosis: 

· Fibroadenoma  (E11):The lump is described as firm, non-tender, and immobile, which can be consistent with benign conditions like fibroadenomas or cysts. These are common benign breast lesions in women in their 40s. Fibroadenomas are usually firm, round, and non-tender, and they tend to be mobile. If the lump is immobile, it could be a more fibrous fibroadenoma or a cyst, which may have become fixed to surrounding tissue

· Solitary cyst of the breast (N60.0):Typically smooth and round, may be tender or non-tender. This can also present as a firm mass, especially if it is not fluid-filled.

Include any appropriate differential diagnosis.

· Differential Diagnosis:

· Malignant neoplasm of breast (C50): The characteristics of the mass (firm, immobile, and non-tender) also raise suspicion for breast cancer (invasive ductal carcinoma or invasive lobular carcinoma). However, these types of malignancies usually present with other concerning features, such as changes in the skin over the breast (e.g., dimpling or redness), nipple discharge, or axillary lymphadenopathy. Madeline does not exhibit these symptoms. The lack of regional lymphadenopathy is somewhat reassuring, but further diagnostic imaging is necessary to assess the mass more thoroughly

· Intraductal carcinoma in situ of unspecified (D05.10): Pertinent positives that would suggest IDCIS include nipple discharge, a history of breast cancer or benign breast conditions, mammographic findings of microcalcifications or architectural distortion, and biopsy showing ductal cells confined to the ducts.Pertinent negatives would include the absence of a palpable mass, normal imaging (especially mammography and ultrasound), and biopsy findings that are benign or do not show in situ carcinoma.

Plan 

What are your next steps and plan of care for this patient? Explain your rationale

· Dx Tests/Lab Test:

· Diagnostic mammogram with breast ultrasound to further characterize the mass. The BI-RADS score from the imaging results will guide further management

· If imaging findings are suspicious (BI-RADS 4 or 5): Biopsy (core needle biopsy or fine needle aspiration) to obtain a tissue sample for histopathology.

Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s),

· Tx/Medication Plan: 

· The treatment for a breast mass depends on whether the mass is benign or malignant.

· The possibility of breast cancer cannot be excluded without further evaluation. Diagnostic imaging and potentially a biopsy will be necessary to confirm the nature of the lump.

· If the mass is benign and asymptomatic, the primary treatment may simply be observation. Regular follow-up imaging (e.g., mammogram or ultrasound) is often recommended, typically every 6-12 months, depending on the mass characteristics

· If the lump is found to be malignant, treatment will vary based on the type, size, and stage of the cancer. Treatment often involves a combination of surgery, radiation therapy, and/or chemotherapy. Medications such as hormone therapy or targeted therapies may also be used depending on the cancer's characteristics.

· OTC pain relievers can help with discomfort: ibuprofen 600 mg PO Q12H PRN #30 0 refills

Explain complications that can occur if patient does not comply with treatment regimen.

· Non-compliance with the recommended treatment regimen for breast masses, whether benign or malignant, can have serious consequences. In benign cases, the primary risks are progression or recurrence of the mass, discomfort, and the potential for a delayed cancer diagnosis. In malignant cases, the risks are much more significant and include cancer progression, metastasis, a reduced chance of survival, and development of treatment resistance. Furthermore, non-compliance can lead to psychological distress, worsening the patient’s overall quality of life. It is essential to educate and support the patient to follow through with recommended treatment and follow-up care

What patient education is important to include for this patient? (Consider including pharmacological, supplements, and non pharmacological recommendations and education)

· Pt. Education: 

· Encourage regular self-breast exams and annual mammograms for women over 40.

· Clinical Breast Exams: Encourage annual or biennial clinical breast exams by a healthcare provider as part of routine preventive care.

· Follow-Up Testing: Emphasize the importance of follow-up testing (imaging, biopsy).

· Pain Management: OTC pain relievers can help with discomfort, w/ appropriate dosing

· Lifestyle Modifications: Maintain a healthy weight, exercise regularly, and limit alcohol and smoking to reduce breast cancer risk.

· Recommend wearing a well-fitting, supportive bra to reduce the discomfort from any breast mass or fibrocystic changes. Encourage her to avoid underwired bras if she experiences significant tenderness.

· Pt educated on red flags and promptly contact healthcare provider if any of these symptoms occur (skin changes, new pain, changes in the size, Unexplained discharge from the nipple)

· Genetic Counseling: Consider genetic counseling for those with a strong family history of breast cancer.

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. 

Subjective

CC: “breast lumps”

HPI: Natalie, G0P0, is a 31-year-old female who came into the clinic complaining of intermittent breast pain. Her pain is described as fullness and soreness in varying degrees mostly moderate pain that is localized within her breast tissues. She reports lumps in the outer quadrants of her breasts but is unsure of the location today. She denies family or personal history of cancers; she menstruates regularly; she denies pregnancy; and she reports using condoms consistently for BCM and STI protection. She denied other complaints and feels healthy overall in this well woman clinic visit.

Medications: 

· Acetaminophen 500 mg rapid release capsules as needed of occasional headaches (takes them about once every other month).

· Over-the-counter daily multivitamins.

· Are you taking other medications particularly birth control pills and/or hormone replacement therapies?

Allergies:

· Allergy to nuts; reaction: rashes

· No known drug allergies

LMP:

· When is your LMP?

Gyn/OB history:

· G0P0

· Menarche age 12 years old

PMH: Denies any medical condition and surgical history. Did you have similar conditions like this in the past? Have you had your breasts screened before? If so, what were the results?

Chronic Illness/ Major trauma: Denies major illnesses, trauma. Any trauma or injury to your breasts or accidentally hitting them on objects?

Family History:

· Father, 61, alive and has HTN and BPH

· Mother, 59, alive and healthy

· Maternal grandmother deceased at 89 years old due to natural causes.

Social History:

· Housing: Lives with parents in a suburban house.

· Habits: Likes hiking with friends, working out, and baking. Is the pain or symptom worse during activity or wearing tight clothing?

· Occupation: Works as an accountant at a tax company. She is also studying for her master’s degree.

· Substance Use: Admits drinking about 3-4 shots of hard drinks on occasional family and friend gatherings. Denies illicit drug use and smoking.

· Sexual Activity: Natalie is single but is currently dating a male about his age. She denies having multiple sexual partners and as stated in the HPI, she uses condoms consistently despite being sexually active.

Review of Systems (ROS)

General: Denies fever or chills. Denies unintentional weight gain or weight loss.

            Head: Denies headaches. Denies migraines.

Breasts: Reports intermittent breast pain with multiple “lumps” bilaterally that are mobile and changes in position. Do you have nipple inversion, significant asymmetry of the breasts, skin changes, roughness, nipple discharge, or any other abnormalities? Where else in your body do you feel those lumps? Did you get sick recently? Can you point to me where exactly the pain is and where you mostly notice the “lumps” are? Every what time of the month do you notice these symptoms? Is it during your menstruation or after? Is there any triggering factor such as mood, weather, changes I disposition? Does it resolve spontaneously? Are the lumps consistently present or do they disappear? When did you notice your symptoms start? Do you feel breast fullness or heaviness during flare ups or sharp pain localized where the lumps are? What is the size? Is it changing in size? Is the size round or irregular? Is the pain coming from the chest wall or from your breast tissues?

            Cardiovascular: Denies chest pain, palpitations, peripheral edema.

            Respiratory: Denies shortness of breath, activity intolerance, asthma. Denies cough.

            GI: Denies constipation but reports hesitancy in defecating due to its induced pain.

            GU: Denies urinary incontinence, urgency, dysuria

Gyn: Denies vaginal discharge, pelvic pain, menses irregularity, itch, heavy menstruation, or dyspareunia. Reports being sexually active without complications.

            Integumentary: Denies hot flashes, thinning of the skin.

Objective Data

Vital Signs:

· T: 98.2 F

· BP: 112/72 mmHg

· P: 72

· RR: 16

· SpO2: 99% on room air

· Height: 62 inches

· Weight: 121 pounds

· BMI: 22.1 (normal)

Physical Exam:

            General: Appears healthy, well-developed, afebrile. In no acute distress.

HEENT: Atraumatic, normocephalic, PERRLA, Normal hearing, normal sinuses. Good dentition, no lymphadenopathy.

Heart: S1 and S2 audible to auscultation, no murmurs, no clicks, no rubs.

Lungs: Unlabored breathing. All lung fields are clear to auscultation bilaterally.

Breast: Ill-defined, diffuse breast consistency, palpable multiple breast lumps bilaterally, lumps are discrete, slightly mobile, and well-circumscribed lumps about 2 cm in size. Mildly tender breasts described as “fullness” and sore when asked. Careful inspection of the breasts looking for redness, dimpling, nipple discharge, and peau d’orange. The technique used for the breast assessment is done by doing gentle and deep palpation via up and down motion scanning throughout the breast tissue for masses. We also pay special attention to the axillary lymph nodes on both sides through gentle palpation to under the armpits and to the sides of sub clavicular breast tissue. Palpation of the entire breast (from the clavicle to the inframammary crease vertically, and the sternum to the midaxillary line horizontally) and axilla is done with the patient sitting and supine.

Gyn: No pelvic tenderness, adnexa normal, no drainage nor swelling. Vulva normal, no lesions, lumps, redness. Pubic hair well-distributed.

GI: bowel sounds present, abdomen is soft and non-tender.

GU: No CVA tenderness, no bladder bulges.

Neuro: Alert and oriented x4. Appropriate. No memory lags.

 

Assessment/ Diagnosis

· 2 Fibroadenosis of breast: Fibroadenosis or fibrocystic changes of the breasts is a general umbrella term for non-specific benign changes in the breasts such as fibrosis and cysts (Golshan, 2020). Natalie has pertinent positive factors such as child-bearing age with regular menstrual cycle, description of “lumps” in the breasts that are not present at the visit. On physical exam, we felt diffuse breast consistency, palpable multiple breast lumps bilaterally, lumps are discrete, slightly mobile, and well-circumscribed lumps. This means that the condition is likely benign due to mobility, well-defined shape, and a bouncy texture when palpated (Golshan, 2020). All of these factors, on top of no family history of cancer and possible hormone change related due to intermittent breast pain described as “fullness” lead to this diagnosis as the presumptive diagnoses we can work on with Natalie. The presentation of s/s may be a cyclic mastalgia. But work up until a definitive diagnosis can be performed by prescribing imaging stated below.

 

· 29 Fibroadenoma of an unspecified breast: Fibroadenoma is a benign solid breast mass that are small, well-defined with a rubbery or firm consistency (Sabel, 2020).Natalie has pertinent positive of the said signs. But until confirmed using core needle biopsy if concerns are strong enough, this remains as a differential diagnosis. Also, fibroadenoma stays within breast tissues. Pertinent negative is the fact that Natalie does not seem to feel the lumps at the visit or consistently.

 

· 0 Mastitis without abscess: Mastitis is the inflammation of the breast tissue presenting with fullness, redness, and breast tenderness (Sabel, 2020). Pertinent positives are Natalie’s complaint of intermittent pain with fullness. However, she has more pertinent negatives such as lumpy feeling, absence of overt breast inflammation on physical exam, and the fact that she is G0P0 and is not breastfeeding. Mastitis is more particular for patients who are introduced with flora common during breastfeeding.

 

Plan

            The most important thing is to differentiate benign fibrocystic changes from malignant conditions.

Diagnostic tests/Lab tests:

· Mammography – recommended for all women > 30 years old with breast mass.

· Mammography continues to be the gold standard for breast cancer screening but has an overall false- negative rate of 10% to 15% ( )

· False- positive results may also occur; 5% to 10% of all screening examinations are reported as abnormal, and 80% to 90% of women with abnormal results do not have breast cancer (American Cancer Society [ACS], 2022).

· Estrogen test, LH test, TSH, and Gonadotrophin test can be drawn to rule out other diagnosis related to hormone and ovulation changes.

· Breast ultrasound can be used as a lower cost but is less sensitive. However, Natalie is > 30 years which can increase the chances of false sensitivity.

· Core Needle Biopsy – can be used as histologic evaluation of suspicious imaging findings and clinical breast examination. In Natalie’s case, CNB may not yet be indicated.

Treatment/Medication/Non-pharmacological Education:

· Oral contraceptive pills can help with cyclic pain (if the issue is hormonal)

· Observation is indicated for patients without significant discomfort.

· Management for benign fibrocystic changes is supportive.

· Use of supportive bra (i.e. sports bra during exercises)

· Apply warm compresses to alleviate breast pain.

· Avoid caffeine

· Use of evening primrose oil (EPO)

· Use of NSAIDs or acetaminophen for mild-moderate pain as needed.

· Provide reassurance and then breast screening based on age.

· Educate about cyclical breast pain

· Cyclical pain is associated with endocrine fluctuations of the menstrual cycle, usually presenting in the week prior to onset of menses (Malherbe & Fatima, 2020). It is frequently bilateral and most severe in the upper outer quadrant of the breasts.

· Tamoxifen 10 mg orally daily for those with severe mastalgia when first-line treatments stated above proved to be unsuccessful.

Referrals:

· As a primary care provider, referral to an OB/GYN doctor or breast surgeon may be warranted should available EBP recommendations do not work.

Health Maintenance:

· Cervical cytology + high-risk HPV testing if not yet done

· For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting) (USPSTF, 2018)

· Our working diagnosis of fibrocystic changes of the breasts present as benign condition. However, if missed, may be concerning for possible development of breast tissue fibroadenoma and/or malignancy in the future. Continues and close monitoring is necessary.

Follow up:

· RTC in 3 weeks once mammography results are up