Breast complaints are highly charged issues. The increasing incidence of breast cancer with age, coupled with the high profile of this disease, creates anxiety in any woman discovering a breast problem. Often, this anxiety creates real barriers in eliciting information helpful in assessment.
Quick access to medical evaluation may provide the patient with the most immediate sense of relief. Most clinics and offices adopt a policy of seeing these patients within a timely fashion for anxiety’s sake alone. Letting patients know that it is your facility’s policy to see all patients with breast complaints promptly, and that an appointment is not being scheduled quickly because of your alarm over her symptoms, may help alleviate some concern.
It also may be helpful to outline for the woman what will take place at her appointment. Patients need to know that a physical examination may not provide all the data necessary to answer her concerns. Reassuring the patient that additional sonograms, mammograms, and surgical evaluation are commonly ordered and may provide helpful information. It is extremely important that young women understand that mammography may not be the most helpful tool in their evaluation. Breast density in young women can interfere with the accuracy of mammographic data. It is not unusual for a young woman in her 20s to be referred directly to a breast surgeon for the simplest of evaluations if sonography or other imaging (such as breast computed tomography [CT]) is not conclusive. Women in this age group need to know that this measure is routine practice and not caused by alarm over the patient’s individual situation.
Common presentation of various breast nodules (Table 15-1) is included in this section.
Table 15-1 Common Presentation of Various Breast Nodules
Usual Age at Presentation
Shape and Consistency
Tenderness and Retractability
Common Features
Simple cysts
30-60 yr, decreasing after menopause except with hormone therapy (HT)
Round, soft, elastic, fluid filled
Often tender; no retraction
Borders well defined, very mobile, single or multiple in number
Fibroadenoma
Most common in young adults, range puberty to 55 yr
Round or lobular, firm
Usually nontender; no retraction
Usually very mobile and well defined
Cancer
30-90 yr; common in midlife and elderly
Irregular or fixed to skin or underlying structures, firm or hard
Usually nontender (except inflammatory); retraction may be present
May be fixed or partially mobile; not often well defined
» BASIC TRIAGE ASSESSMENT FORM FOR BREAST COMPLAINTS
How old are you? ___________________________________________________________
Do you have any history of breast problems? ________________________________
Are you still menstruating? ________________________________________________
When was the first day of your last menstrual cycle? _______________________
Are you taking any hormonal medication? If yes, what and for how long? _____
Have you recently stopped breastfeeding? ___________________________________
Have you recently had a mammogram? If so, where and when? __________________
Breast Discharge
» Key Questions
ASSESSMENT
ACTION
1. Do you have spontaneous nipple discharge?
YES
Go to Question 2.
NO
↓
Go to Question 5.
2. Is the discharge bilateral?
YES
Go to Question 3.
NO
↓
Go to Question 4.
3. Is the discharge milky?
YES
Go to Step A.
NO
↓
Go to Step C.
4. Is the discharge unilateral?
YES
Go to Step B.
NO
↓
Go to Question 5.
5. Do you have to manipulate your breasts to elicit discharge?
YES
Go to Step D.
NO
No further action
» Actions
STEP A: Milky Discharge
Milky discharge (galactorrhea) is common in women who are breastfeeding, have recently given birth, or who experience frequent breast stimulation (e.g., during foreplay). Galactorrhea is also a side effect of many medications (particularly sedatives, antidepressants, antipsychotics, high blood pressure medications, and, rarely, oral contraceptives). Finally, galactorrhea can be indicative of a pituitary tumor.
Unless the patient has recently given birth and is breastfeeding, she should be referred to her provider for evaluation within the next 1 to 2 weeks.
STEP B: Unilateral Discharge
Unilateral discharge (particularly if the fluid is bloody, green, or tan) is highly suggestive of a breast problem. Refer the patient to her provider for evaluation within the next 2 to 3 days.
STEP C: Bloody or Discolored Discharge
Bloody or discolored discharge (whether unilateral or bilateral) is suggestive of a breast problem. Refer the patient to her provider for evaluation within the next 2 to 3 days.
STEP D: Discharge With Breast Stimulation
This is not an uncommon response to vigorous breast manipulation. Ask the patient to refrain from breast stimulation for the next 30 days. If the symptoms persist, instruct her to visit her provider for breast examination.
Breast Lump
» Key Questions
ASSESSMENT
ACTION
1. Have you experienced menopause?
YES
Go to Step A.
NO
↓
Go to Question 2.
2. Are you within 14 days of your next expected menstrual period?
YES
Go to Step B.
NO
↓
Go to Step C.
3. Is there any pain associated with the lump?
YES
Go to Step D.
NO
↓
Go to Question 4.
4. Are you taking any hormonal medication?
YES
Go to Step E.
NO
↓
Go to Question 5.
5. Have you had any reason to have a mammogram during the last 6 months?
YES
Go to Step F.
NO
Go to Step F.
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