1 st peer discussion: Case Scenario 1
Table 1
In your own words include what type of screening (clinical breast exam, self breast exam, screening mammogram) is needed depending on the age and risk factor of the patient.
ACOG
ACS
USPSTF
Women under age 40
Mammogram greater or equal to 40 years of age (ACOG, 2024).
Every 1-3 years in women aged 20-39 years for clinical breast exam.
Breast self-exam is recommended and includes considerations when caring for high-risk women (Alexander, 2017).
Mammogram greater or equal to 40 years of age (American cancer society, 2024).
Every 1-3 years in women aged 20-39 years for clinical breast exam.
Breast self-exam is recommended optional for women equal or greater to 20 years of age (Alexander, 2017).
Age 40-74 years biennially for mammogram (USPSTF, 2023).
Clinical breast exam has insufficient evidence.
Breast self-exam is not recommended (Alexander, 2017).
Women aged 40-49 years
Annual Mammogram greater or equal to 40-49 years of age (ACOG, 2024).
Annually in women greater or equal to 40-49 for clinical breast exam.
Breast self-exam is recommended and includes considerations when caring for high-risk women (Alexander, 2017).
Mammogram yearly greater or equal to 40-49 years of age (American cancer society, 2024).
Every year in women aged 40-49 years for clinical breast exam.
Breast self-exam is recommended optional (Alexander, 2017).
Age 40-49 years biennially for mammogram (USPSTF, 2023).
Clinical breast exam has insufficient evidence.
Breast self-exam is not recommended (Alexander, 2017).
Women aged 50-74 years
Annual Mammogram greater or equal to 50-74 years of age (ACOG, 2024).
Annually in women greater or equal to 50-74 for clinical breast exam
Breast self-exam is recommended and includes considerations when caring for high-risk women (Alexander, 2017).
Annual or Biennially Mammogram greater or equal to 50-54 years of age; 55 and over every 2 years (American cancer society, 2024).
Every year in women aged 50-74 years for clinical breast exam.
Breast self-exam is recommended optional (Alexander, 2017).
Age 50-74 years biennially for mammogram (USPSTF, 2023).
Clinical breast exam has insufficient evidence.
Breast self-exam is not recommended (Alexander, 2017).
Women aged 75 years and older
Age 75 years and older biennially for mammogram if in good health (ACOG, 2024).
Annually in women greater or equal to 75 and older for clinical breast exam.
Breast self-exam is recommended and includes considerations when caring for high-risk women (Alexander, 2017).
Age 75 years and older biennially for mammogram if in good health as expected to live 10 years (American cancer society, 2024).
Every year in women aged 75 years and for clinical breast exam.
Breast self-exam is recommended, but optional (Alexander, 2017).
Age 75 years states that current evidence is insufficient and can harm one who is going to get a mammogram (USPSTF, 2023).
Clinical breast exam has insufficient evidence.
Breast self-exam is not recommended (Alexander, 2017).
Women with dense breasts
Mammogram: US or MRI diagnostics needed for dense breasts for (ACOG, 2024).
Annually in women greater or equal to 40 for clinical breast exam.
Breast self-exam is recommended and includes considerations when caring for high-risk women (Alexander, 2017).
Mammogram: Supplemental screening needed
Every 1 year in women with dense breasts. for clinical breast exam.
Breast self-exam is recommended optional (Alexander, 2017).
Mammogram: Does not recommended supplemental screening (USPSTF, 2023).
Clinical breast exam has insufficient evidence.
Breast self-exam is not recommended (Alexander, 2017).
As you can see each organization has different screening guidelines, it is best to follow the protocols in your clinic for more guidance. Keep these guidelines in mind when answering the case scenario.
Table 2
The American College of Radiology Breast Imagine Reporting and Data Systems (BI-RADS)
Definition
BI-RADS 0
Needs additional imaging evaluation and/or earlier mammograms for comparison (Alexander, 2017).
BI-RADS 1
Negative (Alexander, 2017).
BI-RADS 2
Benign findings (Alexander, 2017).
BI-RADS 3
Probably benign, short interval follow suggested (Alexander, 2017).
BI-RADS 4
Suspicious abnormality; biopsy should be considered (Alexander, 2017).
BI-RADS 5
Highly suggestive of malignancy; action should be taken (Alexander, 2017).
BI-RADS 6
Known biopsy-proven malignancy; action should be taken (Alexander, 2017).
Madeline is a 41-year-old female who complains of a small lump she feels in her right breast. Upon physical examination, you palpate an approximately 2×2 cm firm, non-tender, immobile mass in the right upper outer quadrant of the right breast at approximately 10 oclock, 1 cm above the areola.
Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.
Subjective:
Chief Complaint: 41 y/o complains of small lump in rt breast.
HPI: 41 y/o female presents to the clinic for small lump that she had felt in right breast. Reports that she has not had a mammogram. Patient states she does have a family history of breast cancer and she is concerned.
What other relevant questions should you ask regarding the HPI? How long have you noticed the lump? Has the lump grown in size? Do you only have 1 lump? Or several? Is the lump only on the right breast? Do you have any pain? Any discharge around that nipple? Do you have a regular menstrual period? Have you started menopause?
What other medical history questions should you ask? Have you had a previous mammogram, ultrasound, or MRI?? Do you know the benefits of screening mammogram? Have you continued the clinical breast exams at your annual physical? Do yourself do a breast-self exam? Have you taken any oral contraceptives?
What other social history questions should you ask? Do you drink caffeine? How much caffeine do you drink? Have you experienced any stress? Have you noticed that the lump is an irregular shape?
What other family history questions should you ask? Does your family have a history of breast cancer? Has anyone in your family had breast cancer? If so how old? When did your mother start menopause?
PMH: Colitis
Past Surgical Hx: No significant past surgical hx
Allergies: Latex
Family Hx:
Husband, 33, Alive
Mother, 73, Alive, Diabetes
Father, 76, Alive, High Cholesterol
Sister, 35, Alive, No PMH
Maternal Grandmother, 92, Alive, Seizures
Maternal Grandfather, 93, Alive, Parkinsons
Paternal Grandmother, 95, Deceased, Heart attack
Paternal Grandfather, 91, Deceased, Stroke
Social Hx:
Occupation Engineer
Alchohol Used to drink 1-2 glasses of wine per week
Substance Abuse No hx of substance abuse
Currently lives with sister and husband
Subjective/ROS:
General/Constitutional:
Denies fatigue, chills, or fever.
Cardiovascular:
Denies chest pain. Denies fast heart rate.
Respiratory:
Denies wheezing or trouble breathing.
Skin and Breasts:
No abnormality reported by the patient.
Genitourinary:
Denies pain in abdomen.
Women Only:
Admits to a small lump in right breast.
LMP: 1.23.24
Mental Status/Psychiatric:
Denies history anxiety. Adnits to being a happy person.
Objective:
VS: BP: 128/88, HR: 72, RR: 16, Temp: 99.0,O2 Sat: 99%, HT 510inches WT: 150lb
Physical Exam:
General: Alert and Oriented x4, speaks clearly and comfortably throughout.
BREAST: normal breast exam, Breasts, BL: 2×2 cm firm, non-tender, immobile mass in the right upper outer quadrant of the right breast at approximately 10 oclock, 1 cm above the areola (-) erythema, (-) symmetric at rest, (-) symmetric with pectoral tension, (-) tender to palpation
Nipples, BL: no abnormalities, (-) discharge without pressure, (-) expressed discharge, (-) clear discharge, (-) bloody discharge, (-) purulent discharge, (-) bruising, (-) areolar bleeding.
Axillae BL: no abnormalities, (-) mass, (-) tender to palpation, (-) erythema, (-) pectoral lymphadenopathy, (-) subscapular lymphadenopathy, (-) brachial lymphadenopathy, (-) acanthosis nigricans
RESP: lungs clear to auscultation bilaterally, no rales, wheezes or rhonchi, nonlabored breathing, no use of accessory of muscles of respiration.
CV: RRR
GI: nontender to palpation, no masses
Extremities: (-) edema
DERM: skin warm and dry
Tests will order:
STD panel negative
CBC unremarkable
Blood type B-
HBA1C 3.6%
Pap Smear Negative
Urine No abnormalities
It is crucial to take baseline labs for our patients. Both drawing blood and urine to cover all of our bases.
Assessment:
Diff Dx:
D24.1 Benign neoplasm of right breast
The pertinent positives includes 2×2 cm firm, non-tender, immobile mass in the right upper outer quadrant of the right breast at approximately 10 oclock, 1 cm above the areola.
The pertinent negatives includes nipple discharge and breast pain.
N63.1 Unspecified lump in the right breast
The pertinent positives includes 2×2 cm firm, non-tender, immobile mass in the right upper outer quadrant of the right breast at approximately 10 oclock, 1 cm above the areola.
The pertinent negatives includes tenderness and soreness.
Final Diagnosis:
N60. 21: Fibroadenosis of right breast
The Pertinent positive painless, unilateral, and solid mass.
The Pertinent negative includes lump is immobile
Plan:
Treatment Plan: Mammogram and US for Diagnostics studies to reveal the true size and shape of the lump. Some of these can shrink in size or disappear without any treatment. After collecting and reviewing the findings of the Mammogram and US. A core needle biopsy of the lump would be beneficial to rule out malignancies. These lumps are not cancerous, but it is crucial to rule this out. The very first line of treatment is NSAIDs such as Ibuprofen and oral contraceptives thus lowering cycle related hormones. Running a set of labs prior to starting the OCPs would be necessary due to the potential cause of the lump. Hormone therapies should help as well. However, if the mass does not shrink in size, then surgery will need to take place.
Education: The first information that needs to be relayed and is crucial for screenings of breast cancer is to receive a Mammogram. A yearly Mammogram is recommended to those that are over age of 40. This type of study is considered a primary prevention for health. A fibroid tends to be firm and nontender. These types of lumps are comprised of fibrous tissue. This fibroadenosis is caused by a dominance of estrogen and progesterone deficiency. The use of NSAIDs overtime can also be dangerous instead of the ibuprofen then Tylenol would be a good substitute. It might be beneficial to use both interchangeably. The complication to these medications is black/tarry stool with nausea, and abdominal pain. The selective estrogen receptor modulators and medroxyprogesterone are good hormone therapies. This happens when a shift of hormones develops. The complication to this is that these medications can lead to hot flushes and endometrial cancer. Although this lump can be removed this does not mean that it cannot reoccur. Another complication that can happen from Oral contraceptives are nausea, headaches, and breakthrough bleeding. This is possible that these lumps can resolve on their own. It is a good idea to avoid stimulants such as caffeine, chocolate, and tea. Increase in fiber, vegetables, and fruits for diet. The supplements that would be beneficial are primrose oil, vitamin A, B, and E. The treatment is aimed for both symptomatic relief and education (Sabel, 2024). It is possible that left untreated Madeline might develop breast cancer.
Referral/Follow-up: f/u if lump after Mammogram and US to review findings.
Orders: Mammogram of bilateral breasts and US of right breast.
Recommend an annual physical exam and pap smear every three years with Mammogram yearly.
2nd peer discussion: Case Scenario 1
Table 1
In your own words include what type of screening (clinical breast exam, self breast exam, screening mammogram) is needed depending on the age and risk factor of the patient.
ACOG
ACS
USPSTF
Women under age 40
Clinical breast exam as part of routine health exams, and consideration of mammography for those with increased risk.
Clinical breast exam about every 3 years for women in their 20s and 30s, and optional yearly mammograms for women starting at age 40, depending on individual risk.
Insufficient evidence to recommend routine clinical breast exams or mammography in this age group..
Women aged 40-49 years
Mammography every 1-2 years based on individual risk and patient preference, with shared decision-making.
yearly mammograms are optional for women starting at age 40, with shared decision-making based on individual risk.Yearly mammograms are recommended from age 45
Biennial mammography is recommended for average-risk women aged 50-74; individualized decision-making for those aged 40-49.
Women aged 50-74 years
Mammography every 1-2 years, or as recommended by healthcare provider, based on individual risk and patient preference.
Yearly mammograms are recommended from age 45-54.
Biennial with option for annual screenings for 55 years or older
Biennial mammography is recommended for average-risk women aged 50-74.
Women aged 75 years and older
Continue screening based on individual health and life expectancy, with consideration of patient preferences.
Continue screening as long as the woman is in good health and expected to live at least 10 more years.
Insufficient evidence to recommend for or against mammography in women aged 75 and older.
Women with dense breasts
Consider additional screening, such as ultrasound or MRI, in addition to mammography, based on individual risk and breast density.
Consider supplemental screening with ultrasound or MRI for women with dense breasts and average risk.
Insufficient evidence to recommend for or against additional screening in women with dense breasts.
As you can see each organization has different screening guidelines, it is best to follow the protocols in your clinic for more guidance. Keep these guidelines in mind when answering the case scenario.
Table 2
The American College of Radiology Breast Imagine Reporting and Data Systems (BI-RADS)
Definition
BI-RADS 0
Incomplete assessment. Additional imaging evaluation and/or comparison with prior mammograms are needed.
BI-RADS 1
Negative. The mammogram is interpreted as normal, and there are no signs of cancer.
BI-RADS 2
Benign finding. The mammogram shows findings that are definitely benign, and there is no suspicion of cancer.
BI-RADS 3
Probably benign. There is a finding that is likely benign but needs short-term follow-up to ensure stability.
BI-RADS 4
Suspicious abnormality. There is a suspicious finding that may indicate the presence of cancer. Further evaluation or biopsy may be recommended.
BI-RADS 5
Highly suggestive of malignancy. The mammogram reveals findings highly suspicious for cancer, and biopsy is usually recommended.
BI-RADS 6
Known biopsy-proven malignancy. This category is assigned when there is already a confirmed diagnosis of breast cancer through biopsy.
Madeline is a 41-year-old female who complains of a small lump she feels in her right breast. Upon physical examination, you palpate an approximately 2×2 cm firm, non-tender, immobile mass in the right upper outer quadrant of the right breast at approximately 10 oclock, 1 cm above the areola.
Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.
Chief Complaint (CC): Patient reports a small lump in the right breast.
History of Present Illness (HPI): Madeline notes the lump’s presence without associated pain, tenderness, or changes in the overlying skin. The lump was self-detected.
Subjective:
What other relevant questions should you ask regarding the HPI?
When did you first notice the lump?
Has the lump size or characteristics changed since you first noticed it?
Any pain, tenderness, nipple discharge, or skin changes in the breast?
Any relation of lump changes to the menstrual cycle?
Have you ever had a mammogram? If so, what was the BI-RADS category?
When was your last menstrual period? What is the regularity of the cycles?
Are you using any contraception methods?
Have you had any previous pregnancies? NSVD, C/Section, Abortions?
Have you recently given birth or stopped breastfeeding?
How often do you perform breast self-exams, and when was your last one?
Have you noticed any other changes during your routine breast self-exams?
What other medical history questions should you ask?
Any history of breast infections, cysts, or previous breast surgeries?
Are you on hormonal therapy, such as hormone replacement therapy or oral contraceptives?
Have you received any chest or breast radiation therapy?
Have you had any previous breast conditions or surgeries>
What other social history questions should you ask?
Do you smoke or consume alcohol?
Any occupational exposure to chemicals or environmental factors?
Describe your level of physical activity.
What other family history questions should you ask?
Is there a family history of breast cancer in first-degree relatives (mother, sister, daughter)?
Any family history of ovarian cancer?
Any family history of other cancers, especially in the breast and reproductive organs?
Do you have any known genetic predispositions (BRCA mutations)?
Objective:
Write a detailed focused physical assessment on this patient.
General Appearance:
Observe Madeline’s overall appearance, noting any signs of distress or discomfort.
Assess for signs of nutritional status and general health.
Vital Signs:
Measure blood pressure, heart rate, respiratory rate, and temperature to establish baseline values.
Breast Examination:
Carefully inspect both breasts for any asymmetry, changes in size, shape, or skin texture.
Note any changes in the nipple, such as inversion, discharge, or skin dimpling.
Palpate the entire breast tissue, including the axillary tail and the area around the areola.
Specifically, assess the lump in the right upper outer quadrant:
Note the size, shape, and consistency.
Determine if the lump is mobile or fixed.
Assess tenderness and warmth.
Examine overlying skin for any redness, dimpling, or puckering.
Axillary Examination:
Palpate the axillary lymph nodes for any enlargement or tenderness.
Supraclavicular and Infraclavicular Examination:
Check the supraclavicular and infraclavicular regions for any palpable masses or lymph nodes.
Skin Examination:
Inspect the skin for any signs of systemic conditions or dermatologic issues.
Explain what test(s) you will order and perform, and discuss your rationale for ordering and performing each test.
Mammogram: Rationale – Mammography is the initial imaging modality for breast lumps. It provides detailed images of breast tissue and can detect abnormalities such as masses or microcalcifications. In Madeline’s case, it helps evaluate the characteristics of the lump and assess for any additional lesions (Sabel, 2023).
Breast Ultrasound: Rationale – Ultrasound is useful for further characterizing breast masses identified on mammography. It helps differentiate between solid and cystic lesions, providing additional information about the lump’s composition.
Breast Biopsy: Rationale -If the mammogram and ultrasound indicate a suspicious or inconclusive finding, a biopsy is essential for definitive diagnosis. This procedure involves sampling tissue from the lump for pathological examination, confirming whether it is benign or malignant. (Sabel, 2023).
Breast MRI: Rationale – In certain cases, especially if there are inconclusive findings or a need for further evaluation, breast MRI may be ordered. MRI provides detailed images of breast tissue and can help assess the extent of disease, particularly in cases of known breast cancer.
Assessment/ Diagnosis:
What is your presumptive diagnosis? Why?
Based on the information provided, the presumptive diagnosis for Madeline would be a breast mass. The characteristics of the mass, including its firmness, non-tenderness, immobility, and specific location in the right upper outer quadrant, raise concerns about the possibility of a neoplastic lesion (Sabel, 2023).
Rationale:
The presence of a palpable lump in the breast is a common reason for concern and warrants further evaluation.
The firmness of the mass is suggestive of a solid structure rather than a fluid-filled cyst.
Non-tenderness and immobility are features often associated with more concerning lesions.
The specific location (right upper outer quadrant) aids in localizing the abnormality for further diagnostic workup.
Any other diagnosis or differential diagnosis you would like to add?
Fibroadenoma: Rationale: Fibroadenomas are common benign breast tumors. They are usually firm, mobile, and non-tender. However, any new breast lump should be evaluated to rule out malignancy.
Cyst: Rationale: Fluid-filled cysts are common and often present as mobile, round masses. They are usually tender and can fluctuate in size during the menstrual cycle.
Mastitis: Rationale: Inflammation of the breast tissue, often associated with infection, can present with a lump, redness, warmth, and tenderness. It’s crucial to consider this, especially if there are signs of infection.
Breast Cancer: Rationale: While breast cancer is a concern given the characteristics of the mass, it’s essential to confirm the diagnosis through further imaging and biopsy.
Plan:
What are your next steps and plan of care for this patient? Explain your rationale
Order diagnostic mammogram and ultrasound for further evaluation (see above).
Refer the patient to oncology for biopsy if imaging results are suspicious.
Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s),
Surgery (if cancer is confirmed):
Rationale: Surgical intervention, such as lumpectomy or mastectomy, may be recommended depending on the biopsy results.
Side Effects: Surgical risks, including infection, bleeding, and changes in breast appearance.
Chemotherapy or Radiation (if cancer is confirmed):
Rationale: Adjuvant therapies may be recommended based on the type and stage of breast cancer.
Side Effects: Fatigue, nausea, hair loss, and increased susceptibility to infections.
Hormone Therapy (if cancer is hormone-receptor positive):
Rationale: Hormone-blocking medications may be prescribed to reduce the risk of recurrence.
Side Effects: Hot flashes, joint pain, and increased risk of osteoporosis.
What patient education is important to include for this patient? (Consider including pharmacological, supplements, and non pharmacological recommendations and education)
Explain the biopsy results and the nature of the breast mass.
Depending on the diagnosis, potential treatments, include surgery, chemotherapy, radiation, or hormone therapy.
Provide information on possible side effects and how to manage them.
Self-care practices, stress management, and maintaining a healthy lifestyle.
Regular follow-up appointments and adherence to the treatment plan.
What is the follow-up plan of care?
Schedule regular follow-up appointments with the oncologist.
Conduct imaging studies as recommended by the healthcare team.
Monitor for treatment side effects and adjust the plan as needed.
Explain complications that can occur if patient does not comply with treatment regimen.
Non-compliance with diagnostic tests may lead to delayed detection and treatment of breast cancer.
Failure to adhere to prescribed treatments may result in the progression of the disease and decreased treatment effectiveness.
Complications and adverse outcomes associated with breast cancer may be more severe in cases of non-compliance.
