see attachment
Table 1: Breast Conditions
Table 2: Breast Diagnostic Tests
Co
ndi
tio
n
Definition
Presentation/ Signs
and Symptoms Management
Ma
sta
lgi
a
Breast pain, either
cyclical (related to
menstrual cycle)
or non-cyclical.
Dull, heavy, or aching
breast pain; may involve
one or both breasts.
Supportive bra, NSAIDs, evening
primrose oil, decrease caffeine;
consider hormonal therapy if
severe.
Ma
stit
is
Inflammation/
infection of the
breast tissue,
often in lactating
women.
Localized breast pain,
erythema, swelling, fever,
flu-like symptoms.
Antibiotics (e.g., dicloxacillin or
cephalexin), continued
breastfeeding or pumping, warm
compresses.
Nip
ple
Dis
ch
arg
e
Secretion from
one or both
nipples; can be
physiologic or
pathologic.
Milky, bloody, green, or
clear discharge;
unilateral or bilateral.
Evaluate for underlying cause
(e.g., prolactinoma, duct ectasia);
imaging and labs (prolactin,
TSH); surgery if pathologic.
Bre
ast
Ma
ss
A lump or
thickened area in
the breast tissue.
Palpable lump, may be
mobile or fixed; tender or
non-tender; changes with
menstrual cycle.
Clinical breast exam, imaging
(US/mammogram), biopsy if
suspicious; follow-up or excision
based on findings.
Nip
ple
Ch
an
ge
s
Alteration in
appearance of
nipple (e.g.,
inversion, scaling,
redness).
Retraction, crusting,
Paget’s disease
symptoms, or ulceration.
Diagnostic imaging and biopsy if
suspicious (especially unilateral
or persistent); manage underlying
cause.
Diagnosti
c Test How It’s Helpful in Breast Conditions
Subjective
• Patient: Natalie
• Age: 31
• Sex: Female
• Chief Complaint (CC): “I’ve been having some pain in my breasts off and on, and I think I
sometimes feel lumps in the outer parts, but I’m not sure if I can feel them today.”
• History of Present Illness (HPI):
Natalie is a 31-year-old G0P0 female presenting with complaints of intermittent bilateral
breast pain and self-perceived lumps, primarily in the outer quadrants. The pain has been
present for “a few months” and is described as a dull ache or tenderness, rated 3-4/10 at its
worst, not radiating. She notes it seems to be more pronounced in the week leading up to her
menses and improves after her period starts. She is unsure if she can palpate any distinct
Screenin
g
Mammog
ram
Used in asymptomatic women, typically starting at age 40–50; detects
early signs of breast cancer (e.g., microcalcifications, masses) before
clinically palpable.
Diagnosti
c
Mammog
ram
Performed when there’s a clinical concern (e.g., lump, nipple discharge);
provides additional views to further evaluate abnormalities seen on
screening mammogram.
Breast
Ultrasoun
d
Useful in evaluating breast masses, especially in women < 30 or those
with dense breasts; helps distinguish solid vs. cystic masses.
MRI of
the
Breast
Used for high-risk screening, pre-surgical planning, or evaluation of
ambiguous findings; highly sensitive for invasive cancer but less specific.
Biopsy
(FNA or
CNB)
FNA (Fine Needle Aspiration): evaluates cystic vs. solid mass. CNB (Core
Needle Biopsy): provides tissue architecture for histologic diagnosis of
masses.
Surgical
Biopsy
Performed when core needle biopsy is inconclusive or for complete
excision of suspicious lesion; allows for definitive diagnosis.
lumps today, stating they “seem to come and go.” She denies any nipple discharge, skin
changes (dimpling, redness, puckering, rash), or axillary swelling. No history of breast
trauma. The symptoms cause her some anxiety, prompting this visit. She performs breast
self-exams “occasionally” but is not consistent.
• Past Medical History (PMH):
o No chronic illnesses.
o No prior breast issues reported.
o Childhood illnesses: Unremarkable.
o Immunizations: UTD per patient report.
o Hospitalizations/Surgeries: None reported.
• Medications:
o Occasional ibuprofen for menstrual cramps or headaches.
o No daily prescription medications.
o No hormonal contraceptives currently or in the recent past.
• Allergies:
o No Known Drug Allergies (NKDA).
• Family History (FH):
o Mother: Alive, age 58, HTN.
o Father: Alive, age 60, hyperlipidemia.
o Siblings: One brother, age 34, healthy.
o No family history of breast, ovarian, or other cancers.
• Social History (SH):
o Occupation: “Works as a graphic designer.”
o Marital Status/Living Situation: “Single, lives alone.”
o Tobacco: Denies.
o Alcohol: Reports 2-3 glasses of wine per week.
o Illicit Drugs: Denies.
o Diet: Reports a generally healthy diet, consumes 1-2 cups of coffee daily.
o Exercise: Walks 3-4 times per week for 30 minutes.
o Sexual History: Currently sexually active with one male partner. Uses condoms consistently
for contraception and STI protection.
o Stress: Reports moderate work-related stress.
• Review of Systems:
o Constitutional: Denies fever, chills, unexplained weight loss or gain. Reports some fatigue,
attributes to work.
o Skin: Denies rashes, lesions, or itching other than as described for breasts.
o HEENT: Denies headaches (other than occasional), vision changes, sore throat.
o Cardiovascular: Denies chest pain, palpitations.
o Respiratory: Denies cough, shortness of breath.
o GI: Denies nausea, vomiting, diarrhea, constipation.
o GU: Reports regular menses, LMP ~2 weeks ago. Cycle length 28-30 days, duration 4-5
days, moderate flow. Denies dysuria, hematuria, unusual vaginal discharge. Not currently
pregnant (confirmed by UPT in office).
o Musculoskeletal: Denies joint pain or swelling.
o Neurological: Denies dizziness, syncope, focal weakness.
o Endocrine: Denies heat/cold intolerance, polyuria, polydipsia.
o Psychiatric: Reports some anxiety related to breast symptoms. Denies history of depression.
o Hematologic/Lymphatic: Denies easy bruising or bleeding. Denies swollen glands other than
what she perceives in breasts.
o Breasts: As per HPI.
Objective
• Vitals:
o BP: 118/74 mmHg (left arm, sitting)
o HR: 72 bpm, regular
o RR: 16 breaths/min
o Temp: 98.4°F (oral)
o Ht: 5’5″ (165 cm)
o Wt: 140 lbs (63.5 kg)
o BMI: 23.3
• General Appearance: Well-nourished, well-developed female in no acute distress. Alert and
oriented x4. Cooperative.
• Physical Exam:
o Breasts:
▪ Inspection (patient sitting, arms at sides, overhead, and on hips): Breasts symmetrical. Skin
appears normal in color and texture, without dimpling, puckering, erythema, edema, or peau
d’orange. Nipples everted bilaterally, no visible discharge, rash, or ulceration. Areolae WNL.
No visible masses.
▪ Palpation (patient supine with arm overhead on side being examined):
• Right Breast: Diffusely fibroglandular tissue noted throughout, particularly prominent in the
upper outer quadrant (UOQ). Mild tenderness to palpation in UOQ. No discrete, dominant,
or suspicious masses palpated. No nipple discharge elicited on gentle compression.
• Left Breast: Diffusely fibroglandular tissue noted throughout, particularly prominent in the
UOQ. Mild tenderness to palpation in UOQ. No discrete, dominant, or suspicious masses
palpated. No nipple discharge elicited on gentle compression.
▪ Axillary Lymph Nodes: No palpable axillary lymphadenopathy bilaterally.
▪ Supraclavicular/Infraclavicular Lymph Nodes: No palpable lymphadenopathy bilaterally.
o Chest/Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi. Chest wall
non-tender to palpation.
o Heart: RRR, S1S2 normal, no murmurs, gallops, or rubs.
• Labs/Diagnostics:
o Urine Pregnancy Test (UPT) in office: Negative.
Assessment
1. Fibrocystic Breast Changes (N60.19 – Other benign mammary dysplasia): Patient’s
symptoms of intermittent, cyclical bilateral breast pain and tenderness, with palpation of
diffuse fibroglandular tissue more prominent in UOQs, without a discrete dominant mass on
today’s exam, are highly consistent with fibrocystic changes. Her age and regular menses
support this.
2. Mastalgia, cyclical (N64.4): The reported breast pain that correlates with her menstrual
cycle is characteristic. This is often a component of fibrocystic changes.
3. Anxiety related to breast symptoms (F41.9 – Anxiety disorder, unspecified): Patient
reports anxiety concerning her breast symptoms, which is a common reaction.
4. Health Maintenance / Contraceptive Counseling (Z01.419 – Encounter for routine
gynecological examination without abnormal findings, Z30.09 – Encounter for other
general counseling and advice on contraception): Patient uses condoms consistently,
which is appropriate. Routine well-woman screening discussed.
Differential Diagnoses Considered & Ruled Out/Less Likely:
• Breast Malignancy (C50.-): Less likely given age, lack of family history, cyclical nature of
symptoms, and absence of discrete dominant mass or suspicious skin/nipple changes on
exam. However, always a consideration with breast complaints.
• Fibroadenoma (D24.-): Typically presents as a discrete, mobile, rubbery mass. No such
mass palpated today.
• Costochondritis (M94.0): Possible if pain were more localized to costosternal junctions and
reproducible with pressure, but her description points more to breast tissue.
• Mastitis (N61): Unlikely in non-lactating female without signs of infection (erythema,
warmth, fever).
Plan
1. Fibrocystic Breast Changes/Mastalgia:
a. Reassurance: Educated patient on the benign nature of fibrocystic breast changes,
explaining that they are common and hormonally influenced. Reassured that current clinical
findings are not suspicious for malignancy.
b. Symptom Management:
i. Advised wearing a well-fitting, supportive bra, especially during exercise and
premenstrually.
ii. Suggested warm compresses PRN for discomfort.
iii. Recommended NSAIDs (e.g., ibuprofen 400-600mg Q6-8H PRN) starting a few days before
expected menses and continuing through the first few days of her period for pain relief.
iv. Discussed potential benefit of reducing caffeine intake; patient amenable to trial.
v. Briefly mentioned Vitamin E (400 IU daily) and Evening Primrose Oil as options some
women find helpful, though evidence is mixed; patient can consider if other measures are
insufficient.
c. Education:
i. Educated on breast self-awareness (BSA): Encourage her to become familiar with the normal
feel of her breasts throughout her cycle and to report any new, persistent, or distinctly
different lumps, skin changes, or nipple discharge. Provided handout on BSA.
ii. Explained signs/symptoms that warrant prompt re-evaluation (e.g., a new lump that doesn’t
resolve after one menstrual cycle, skin dimpling/puckering, bloody nipple discharge,
persistent focal pain).
2. Anxiety:
a. Acknowledged her anxiety and validated her concerns. Reassurance regarding the benign
nature of current findings should help alleviate some anxiety.
b. Encouraged open communication and to return if anxiety persists or worsens despite
reassurance.
3. Health Maintenance:
a. Patient is G0P0 and uses condoms consistently. Reminded her of the importance of continued
STI protection.
b. Discussed routine health screenings. As she is 31, she is due for cervical cancer screening
(Pap smear and HPV co-testing) if not done in the last 3-5 years. Advised scheduling a well-
woman exam if due.
4. Diagnostics:
a. No imaging (mammogram or ultrasound) indicated at this time given her age, low-risk
profile, cyclical symptoms, and benign clinical breast exam findings today (no dominant
mass).
b. Will consider breast ultrasound if symptoms persist/worsen, a dominant mass is palpated in
the future, or if patient anxiety remains high despite reassurance and conservative measures.
5. Follow-up:
a. RTC in 2-3 months for re-evaluation of breast symptoms, or sooner if she notes any new or
worsening concerns, particularly a persistent lump.
b. Advised her to keep a symptom diary, noting pain and lump perception in relation to her
menstrual cycle.
c. Encouraged to schedule a well-woman exam for routine GYN care if due.
