see attachment
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.
