35-y.o. woman is seen in the office with a chief complaint of a breast mass

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.

• You are the provider, so in addition to knowing disease process and management, patient will also look to you for what to do. What additional questions should you ask the patient and why?
• What should be included in the physical examination at this visit?
• What are the possible differential diagnoses at this time?
• What tests should you order and why?
• How should this patient be managed?

Students are expected to:

1. Post an initial substantive response of to each questions as an FNP. Use Diagnostic Reasoning to answer each question.
2. Please be sure to validate your opinions and ideas with in text citations and references in APA format.
3. References and citations should conform to the APA 6th edition.
4. Substantive comments add to the discussion and provide your fellow students with information that will enhance the learning environment.
5. The peer postings should be at least one paragraph (approximately100 words)

Timothy’s Response:

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.

According to Laronga (2017), Breast cancer is the most common female cancer in the United States, the second most common cause of cancer death in women (after lung cancer), and the leading cause of death in women ages 45 to 55. When found and treated early, breast cancer is most often curable. Breast cancer deaths have decreased by one-third or more over the past three decades. This is due in part to increased screening, as well as earlier and improved treatment for breast cancer. Screening usually detects the disease at an earlier stage, when the chances of successful treatment are higher. Early detection and treatment of breast cancer improve survival because the breast tumor can be removed before it has a chance to spread (metastasize). In addition, there are treatments that can be used to prevent cancer cells that have escaped the breast from growing in other organs.

What additional questions should you ask the patient and why?

According to Esserman and Joe (2017), the first question is to ask the patient is there is a family history of any type of breast cancer, especially a mother, sister, or daughter to help rule out past medical history of any possible carry genes such as the BRCA genes. The provider would also question the patient about their menstrual cycle and question if the knot was more prevalent during this time. The provider would need to ask when the knot or mass was found and has there been a change in its size. The provider would also need to know if the patient had any fever or chills and if any redness or discharge was noted from the nipple or dimpling of the skin of the breast.

What should be included in the physical examination at this visit?

According to Esserman and Joe (2017), there should be a complete breast exam using the pads of the finger and in a circular motion move upward and outward to under the arm and chest. The lymph nodes should be felt for swelling and tenderness. The main reason for the breast exam is to help the provider find cancer early, so it might be easier to treat and lowers the chances of the patient dying of breast cancer.

What are the possible differential diagnoses at this time?

According to Laronga (2017), some differential diagnoses could be mastitis, inflammatory carcinoma, benign breast disease, lymphoma, and fibrocystic disease.

What tests should you order and why?

According to Laronga (2017), a mammogram should be ordered, because Mammograms are currently the best screening modality to detect breast cancer. A breast ultrasound can be ordered and sometimes even a breast MRI can be used. A breast biopsy (needle biopsy) can be used to help confirm the diagnosis.

How should this patient be managed?

The management of the patient will be determined by the type of cancer or non-cancer the patient might have. According to Laronga (2017), many patients have success with surgery while others might need chemotherapy, radiation, and possible hormonal treatments. Optimal management in most cases requires collaboration between surgeons (breast cancer surgeons and reconstructive surgeons, who are typically plastic surgeons) and physicians who specialize in radiation and medical oncology. Each woman should discuss the available treatment options with her doctors to determine what treatment is best for her.

References

Esserman, L. J., & Joe, B. N. (2017). Clinical features, diagnosis, and staging of newly diagnosed breast cancer. UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-feature…

Laronga, C. (2017). Breast cancer guide to diagnosis and treatment (Beyond the Basics). UpToDate. Retrieved from https://www.uptodate.com/contents/breast-cancer-gu…

Mirely’s Response:

Palpable breast masses are common and typically benign, but proficient assessment and prompt diagnosis are indispensable to rule out malignancy (Klein, 2005). According to Dains, Bauman & Scheibel (2016), approximately 90% of breast lumps are discovered by the patient or her partner before having a diagnosis using clinical breast examination or mammography. The three most likely causes of breast lumps are fibro-adenomas, fibrocystic breast changes, and breast carcinomas. A comprehensive clinical breast examination, imaging, and tissue sampling are needed for a conclusive diagnosis. In the presence of a palpable mass or nipple discharge, a diagnostic mammogram is necessary to identify palpable lumps or abnormal screening mammograms (Dains, Bauman & Scheibel, 2016). Further, fine-needle aspiration is fast, inexpensive, and precise, and it can distinguish solid and cystic masses (Klein, 2005).

The evaluation process of a patient that presents with findings of a breast lump needs to focus in the history of the breast lump, past medical history of the patient and a thorough examination and diagnostic testing. Therefore, asking key questions gives the clinician clues of whether the lump is likely to be malignant. Some key questions include:

• How long has the lump been present?
• Is the lump getting bigger, worse, or more painful?
• Is the lump in one breast and in one area?
• Last menstrual period
• Is there any discharge from the nipple and description of discharge?
• Does the patient have any history of trauma to the breast or recent infection?
• Is there a past history of surgical interventions to the breast?
• Does the patient have any risk factors for breast cancer or history of cystic breast?
• Is there any family history of breast cancer?

During physical examination it is essential that the clinician performs a complete breast exam as well as a thorough evaluation of lymph nodes. According to Laronga (2017), the first sites of breast cancer spread is to the axillary lymph nodes. The

axillary lymph nodes can become enlarged and are usually felt during a breast examination. The clinician needs to pay close attention to the lump appearance, size, tender versus non-tender, soft versus hard and borders. According to Dains, Bauman & Scheibel (2016), a breast lump that is hard, non-tender, fixed, borders, irregular or not discrete, with increase vessel patterns and with or without nipple discharge is suggestive of malignancy.

Differential diagnoses for a single breast mass include:

• Breast cancer (typically older than 35 years)
• Cysts (typically younger than 35 years)
• Fibro-adenoma (commonly seen in adolescence)
• Abscess (usually the patient have a history of mastitis)

In this particular case, the patient is presenting with some anxiety related to the finding of the lump. Therefore, it is essential that the patient receives reassurance that not all breast lump is due to cancer and that fibrocystic symptoms are seen frequently in women age 30-50 years (Dains et al., 2016). However, it is essential that further testing is done to rule out any malignancies. Initially, the patient should have a diagnostic mammogram and come back to the clinic as soon as possible to evaluate the results and the need for further evaluation and treatment.

References

Dains, J. O., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. louis, MO: Elsevier Mosby. tsite=enterprise&gclid=Cj0KCQjw37fZBRD3ARIsAJihSr2S6v4LuJkhm6rOqaQZiXyxBEeTqaXAelSDKHMDQ6m5fHsLht-d00EaApMPEALw_wcB

Klein, S. (2005, May 1). Evaluation of palpable breast masses. Retrieved from https://www.aafp.org/afp/2005/0501/p1731.html

Laronga, C. (2017). Breast cancer guide to diagnosis and treatment (Beyond the Basics). UpToDate. Retrieved from https://www.uptodate.com/contents/breast-cancer-gu…

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