Diagnostic Tests for Breast lump
Breast lump: Diagnostic Tests
The list of diagnostic tests
mentioned in various sources as
used in the diagnosis of Breast lump
includes:
Breast lump Tests: Book Excerpts
Home Diagnostic Testing
These home medical tests may be relevant to Breast lump:
- Colon & Rectal Cancer: Home Testing
- Menopause: Related Home Testing:
- Vaginal Health: Home Testing:
- Breast Cancer: Related Home Tests:
- Cancer-Related Home Testing:
Breast lump Diagnosis: Book Excerpts
Diagnosis of Breast lump: medical news summaries:
The following medical news items
are relevant to diagnosis of Breast lump:
Diagnostic Tests for Breast lump: Online Medical Books
16 MEDICAL BOOKS ONLINE!
Review excerpts from medical books online, free, without registration,
for more information about the diagnostic tests for Breast lump.
BREAST MASS:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
A breast mass is a clear indication for a referral to a general surgeon. The general surgeon will probably perform mammography and a biopsy before proceeding with surgery. If a cystic lesion is suspected, ultrasonography may be done, followed by fine-needle aspiration and biopsy. When there is a definite mass on physical examination, surgery is indicated even if mammography and other tests are negative.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
HEAD MASS OR SWELLING:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
A skull x-ray will help distinguish the bone lesions, whereas aspiration or biopsy will help distinguish the others. Referral to the appropriate specialist would be the most cost-effective approach.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
BREAST DISCHARGE:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
If there is a bloody discharge, one should not hesitate to refer the patient to a general surgeon, who will probably order mammography and perform a biopsy. The type of biopsy may be either a fine-needle aspiration or fine-needle biopsy or excisional biopsy, but the general surgeon can decide which is appropriate for any given patient. A unilateral nonbloody discharge may be studied further by ordering tests for occult blood, cytology, and mammography before referral. Remember that exploratory surgery may be the only way to get a diagnosis.
If the discharge is bilateral and milky, a serum prolactin should be ordered. If the prolactin is high, referral to an endocrinologist is probably the best step to take next. The endocrinologist will probably order a CT scan of the brain and pituitary and do further workup studies based on his examination.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
VULVAL OR VAGINAL MASS:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Referral to a gynecologist or urologist can obviate an expensive diagnostic workup in most cases. The primary care physician may wish to treat acute bartholinitis or vulvitis, however. A culture and sensitivity is the only procedure required in those cases.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
FEMORAL MASS OR SWELLING:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Surgical consultation may be wise at the outset. A reducible mass would suggest a femoral hernia, but an upper GI series with a small bowel follow-through would confirm this diagnosis. Of course, if it is felt that the femoral hernia is irreducible, this study would not be done, and exploratory surgery would be indicated. If the mass is suspected to be a lymph node, a biopsy should be done. If the mass is suspected to be an abscess, an incision and drainage should be done. If tuberculosis is suspected, a tuberculin test as well as an AFB smear and culture should be done. If the mass is suspected to be a saphenous varix, venography will confirm the diagnosis. Exploratory surgery of the groin will clarify the diagnosis in confusing cases.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
RECTAL MASS:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine laboratory tests include a CBC, sedimentation rate, and urinalysis. A smear and culture should be made of any rectal or vaginal discharge. Most cases will be diagnosed by anoscopy and proctoscopy. A pelvic ultrasound and CT scan of the abdomen and pelvis may be useful in evaluating ectopic pregnancy and other gynecologic disorders. Ultrasound of the prostate may also be done to evaluate a prostatic mass. A gynecologist, proctologist, or urologist should be consulted in difficult cases.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Nipple retraction:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient when she first noticed the nipple retraction. Has she experienced other nipple changes, such as itching, discoloration, discharge, or excoriation? Has she noticed breast pain, lumps, redness, swelling, or warmth? Obtain a history, noting risk factors of breast cancer, such as a family history or previous malignancy.
Carefully examine both nipples and breasts with the patient sitting upright with her arms at her sides, with her hands pressing on her hips, with her arms overhead; and leaning forward so her breasts hang. Look for redness, excoriation, and discharge; nipple flattening and deviation; and breast asymmetry, dimpling, or contour differences. (See Differentiating nipple retraction from inversion.)
Try to evert the nipple by gently squeezing the areola. With the patient in a supine position, palpate both breasts for lumps, especially beneath the areola. Mold breast skin over the lump or gently pull it up toward the clavicle, looking for accentuated nipple retraction. Also, palpate axillary lymph nodes.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Breast nodule [Breast lump]:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient reports a lump, ask her how and when she discovered it. Does the size and tenderness of the lump vary with her menstrual cycle? Has the lump changed since she first noticed it? Has she noticed other breast signs, such as a change in breast shape, size, or contour; a discharge; or nipple changes?
Is she breast-feeding? Does she have fever, chills, fatigue, or other flulike signs or symptoms? Ask her to describe any pain or tenderness associated with the lump. Is the pain in one breast only? Has she sustained recent trauma to the breast?
Explore the patient's medical and family history for factors that increase her risk of breast cancer. These include a high-fat diet, having a mother or sister with breast cancer, or having a history of cancer, especially cancer in the other breast. Other risk factors include nulliparity and a first pregnancy after age 30.
CULTURAL CLUE: Breast cancer incidence and mortality are about five times higher in North America and northern Europe than in Asia and Africa.
Next, perform a thorough breast examination. Pay special attention to the upper outer quadrant of each breast, where one-half of the ductal tissue is located. This is the most common site of malignant breast tumors.
Carefully palpate a suspected breast nodule, noting its location, shape, size, consistency, mobility, and delineation. Does the nodule feel soft, rubbery, and elastic or hard? Is it mobile, slipping away from your fingers as you palpate it, or firmly fixed to adjacent tissue? Does the nodule seem to limit the mobility of the entire breast? Note the nodule's delineation. Are the borders clearly defined or indefinite? Does the area feel more like a hardness or diffuse induration than a nodule with definite borders?
Do you feel one nodule or several small ones? Is the shape round, oval, lobular, or irregular? Inspect and palpate the skin over the nodule for warmth, redness, and edema. Palpate the lymph nodes of the breast and axilla for enlargement.
Observe the contour of the breasts, looking for asymmetry and irregularities. Be alert for signs of retraction, such as skin dimpling and nipple deviation, retraction, or flattening. (To exaggerate dimpling, have your patient raise her arms over her head or press her hands against her hips.) Gently pull the breast skin toward the clavicle. Is dimpling evident? Mold the breast skin and again observe the area for dimpling.
Be alert for a nipple discharge that's spontaneous, unilateral, and nonmilky (serous, bloody, or purulent). Be careful not to confuse it with the grayish discharge that can be elicited from the nipples of a woman who has been pregnant. (See Breast nodule: Common causes and associated findings, page 106.)
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Nipple retraction:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient when she first noticed retraction of the nipple. Has she experienced other nipple changes, such as itching, discoloration, discharge, or excoriation? Has she noticed breast pain, lumps, redness, swelling, or warmth? Obtain a history, noting risk factors of breast cancer, such as a family history or previous malignancy.
Carefully examine both nipples and breasts with the patient sitting upright with her arms at her sides, with her hands pressing on her hips, and with her arms overhead; and with the patient leaning forward so her breasts hang. Look for redness, excoriation, and discharge; nipple flattening and deviation; and breast asymmetry, dimpling, or contour differences. (See Differentiating nipple retraction from inversion.)
Try to evert the nipple by gently squeezing the areola. With the patient in a supine position, palpate both breasts for lumps, especially beneath the areola. Mold breast skin over the lump or gently pull it up toward the clavicle, looking for accentuated nipple retraction. Also, palpate axillary lymph nodes.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Breast nodule [Breast lump]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If your patient reports a lump, ask her how and when she discovered it and whether its size and tenderness vary with her menstrual cycle. Has the lump changed since she first noticed it? Has she noticed any other breast signs, such as a change in breast shape, size, or contour; a discharge; or nipple changes?
Is she breast-feeding? If so, does she have fever, chills, fatigue, or other flulike signs or symptoms? Ask her to describe any pain or tenderness associated with the lump. Is the pain in one breast only? Has she sustained recent trauma to the breast?
Explore the patient’s medical and family history for factors that increase her risk of breast cancer. These include a high-fat diet, having a mother or sister with breast cancer, or having a history of cancer, especially cancer in the other breast. Other risk factors include nulliparity and a first pregnancy after age 30.
Cultural Cue: Breast cancer incidence and mortality are about five times higher in North America and northern Europe than in Asia and Africa.
Next, perform a thorough breast examination. Pay special attention to the upper outer quadrant of each breast, where one-half of the ductal tissue is located. This is the most common site of malignant breast tumors.
Carefully palpate a suspected breast nodule, noting its location, shape, size, consistency, mobility, and delineation. Does the nodule feel soft, rubbery, and elastic or hard? Is it mobile, slipping away from your fingers as you palpate it, or firmly fixed to adjacent tissue? Does the nodule seem to limit the mobility of the entire breast? Note the nodule’s delineation. Are its borders clearly defined or indefinite? Does the area feel more like a hardness or diffuse induration than a nodule with definite borders?
Do you feel one nodule or several small ones? Is the shape round, oval, lobular, or irregular? Inspect and palpate the skin over the nodule for warmth, redness, and edema. Palpate the lymph nodes of the breast and axilla for enlargement.
Observe the contour of the breasts, looking for asymmetry and irregularities. Be alert for signs of retraction, such as skin dimpling and nipple deviation, retraction, or flattening. (To exaggerate dimpling, have your patient raise her arms over her head or press her hands against her hips.) Gently pull the breast skin toward the clavicle. Is dimpling evident? Mold the breast skin and again observe the area for dimpling.
Be alert for a nipple discharge that’s spontaneous, unilateral, and nonmilky (serous, bloody, or purulent). Be careful not to confuse it with the grayish discharge that can be elicited from the nipples of a woman who has been pregnant. (See Breast nodule: Causes and associated findings.)
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Breast Mass:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Inspection. Inspect the breasts for symmetry, contour, skin retraction, rashes, peau d’orange, nipple discharge, erythema, or edema.
1. Symmetry and contour can be disrupted on any breast. Retraction suggests either chronic inflammation or BC caused by skin adherence to the mass.
2. Peau d’orange is a puckering or indentation of the skin over a mass. A rash can be related to Paget’s disease with a related ductal carcinoma.
B. Palpation and compression. Palpate both breasts, including the nipple and areolar region. Palpate the supraclavicular, infraclavicular, and axillary region for adenopathy. Evaluate the consistency, regularity, location, mobility, and tenderness of the mass. Hard, immobile, irregular masses raise the suspicion for BC. Smooth, cystic, or rubbery masses suggest a cyst or fibroadenoma. Fibrocystic changes are often nondiscrete and irregular, but are also mobile and relatively soft. Compressing the nipple may express a discharge (Chapter 11.6).
Testing
A. Imaging studies. The mammogram is used to characterize the nature of the mass and to provide an assessment of the remainder of the breast tissue and the contralateral breast. It is not a diagnostic procedure. Ultrasound is used to characterize a mass as solid or cystic or to identify masses that may not be identified by mammography. The ultrasound is helpful in evaluating a mass in a patient aged less than 30 years and it can be used as an adjunct in performing aspiration or a biopsy for the indeterminate lesion.
B. Fine needle aspiration (FNA) (2). The FNA can be used to obtain tissue or fluid in a palpable mass. Fluid aspiration plus resolution of the mass suggests a cystic origin. Grossly bloody fluid demands further evaluation of the mass. A cystic mass in a postmenopausal woman not on ERT requires a more thorough evaluation.
1. If the mass resolves, reexamine the breast in 4 to 6 weeks. If the fluid reaccumulates, reaspirate.
2. Residual mass or asymmetry after aspiration requires mammography and biopsy. If no aspirate is obtained, proceed with excisional biopsy.
C. FNA biopsy (FNAB) (4). The sensitivity of FNAB is 0.65 to 0.98 and the specificity is 0.34 to 1.0. The result of this procedure provides material for a cytologic examination. Correlation with imaging studies must be concordant in conclusion or excisional biopsy is indicated. Imaging guidance is indicated for a nonpalpable mass. Atypia of any degree warrants excisional biopsy.
D. Triple test for solid mass (3). The triple test includes physical examination, imaging findings, and cytology via FNAB. The technique demonstrates a sensitivity of 97% to 100%, with a specificity of 98% to 100% (3). Concordance for benign findings allows no further testing. Malignant cytopathology requires excisional biopsy. Inconclusive results without concordance requires open excisional biopsy.
E. Open excisional biopsy. A lesion that is highly suspicious on clinical examination or mammography is best evaluated with open biopsy and excision. Atypical cells on biopsy also require a more definitive tissue diagnosis.
Diagnostic assessment
The evaluation of a breast mass requires knowledge of BC risk factors and the characteristics of benign and malignant lesions. Characterizing the consistency and mobility of the mass combined with information about the patient’s age and menopausal status helps to provide an initial evaluation of the risk for BC. It is important to know what resources and skills are accessible in the community when selecting a diagnostic modality. Sensitivity to the patient’s fears, diligent follow-up, and communication are important in the care of the patient and to reduce medicolegal risk. If a patient remains fearful or uncomfortable with the evaluation, referral for a second opinion is a wise move.
References
1. White G, Griffith C, Nenstiel R, Dyess D. Breast cancer: reducing mortality through early detection. Clinician Rev 1996;6(9):77–79, 83–84, 100–106.
2. Osuch J, Bonham V, Morris L. Primary care guide to managing a breast mass: step-by-step workup. Medscape Women’s Health 1998;3:5.
3. The Uniform Approach to Breast Fine-Needle Aspiration Biopsy. [Editorial Opinion]. National Cancer Institute Conference. Am J Surg 1997;174(4):371–385.
4. Andolsek KM, Copeland J. Conditions of the breast. In: Taylor RB, ed. Family medicine: principles and practice, 5th ed. New York: Springer-Verlag; 1998.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Mediastinal Mass:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. A general examination before an x-ray study gives clue to a mediastinal mass: vital signs, especially temperature, heart rate, and weight; check for pallor, skin lesions, lymphadenopathy, thyromegaly, splenomegaly, other abdominal or pelvic organomegaly or masses, rashes, weakness; auscultate lungs for wheezes, rales, and rhonchi.
B. Focused reexamination after a mass is detected. Vital signs, especially temperature, heart rate, and documentation of weight loss; check carefully for cervical adenopathy (suitable for biopsy), evidence of thyromegaly, voice quality, airway patency sitting and supine; and observe the swallowing function. Auscultate the lungs for wheezes, rales, rhonchi; the heart for pericardial rubs; recheck for adenopathy (total body), check skin for melanoma, check testes for masses, and repeat the pelvic examination for ovarian masses.
Testing
A. Clinical laboratory tests will depend on the index of suspicion, based on the most common diagnoses in the anatomic location. These may include complete blood count, erythrocyte sedimentation rate, lactic dehydrogenase, alpha fetoprotein, beta fraction human growth hormone, serum calcium, parathormone, gamma globulins, serum antiacetylcholine receptor antibody, purified protein derivative skin test, and HIV antibody screening.
B. Imaging studies. Any patient, but especially smokers or exsmokers, with unexplained peripheral adenopathy, unexplained cough, or any of the aforementioned symptoms, should have a chest x-ray study after no more than 2 to 3 weeks of symptomatic treatment. Any mediastinal mass seen requires a CT with iodinated bolus. The indications for mediastinal MRI are suspected vascular lesion, equivocal CT findings, posterior or paravertebral masses and neurogenic tumors, and suspected tumor recurrence so that scarring can be delineated from tumor. The MRI should be ordered with T1- and T2-weighted images and gadolinium-enhanced T1 images.
Diagnostic assessment
Correlation of the clinical and imaging picture is paramount in deciding the extent of the investigation of a mediastinal mass, because of the fairly predictable location pattern of various lesions. A patient with acute, searing chest pain and mediastinal widening will need emergent attention for thoracic aortic dissection. An anterior solid mass in a patient with cough and weight loss demands a tissue diagnosis and, if operable, surgical extirpation. A posterior cystic mass in a healthy patient may allow close follow-up. However, much overlap is seen (6), and diagnostic accuracy is better based on direct clues (e.g., tissue diagnosis) and on solid clinical judgment to include surgical diagnosis or treatment or medical or oncologic methods, if inoperable.
References
1. Strollo DC, Rosado-de-Christenson ML, Jett JR. Primary mediastinal tumors. Part I: Tumors of the anterior mediastinum. Chest 1997;12(2):511–522.
2. Giron J, Fajadet P, Sans N, et al. Diagnostic approach to mediastinal masses. Eur J Radiol 1998;27(1):21–42.
3. Laurent F, Latrabe V, Lecesne R, et al. Mediastinal masses: diagnostic approach. Eur Radiol 1998;8(7):1148–1159.
4. Mediastinal or hilar enlargement. In: Burgener FA, Kormano M. Differential diagnosis in conventional radiology, 2nd revised ed. London: Thieme Medical Publishers, 1991.
5. Strollo DC, Rosado-de-Christenson ML, Jett JR. Primary mediastinal tumors. Part II. Tumors of the middle and posterior mediastinum. Chest 1997;112(5):
1344–1357.
6. Ahn JM, Lee KS, Goo JM, Song KS, Kim SJ, Im JG. Predicting the histology of anterior mediastinal masses: comparison of chest radiography and CT. J Thorac Imaging 1996;11(4):265–271.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Scrotal Mass:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Palpation of scrotum and contents:
1. Determine the orientation of the testicle. A torsed testicle is usually retracted upward and rotated to an abnormal position. This may be indicated by an epididymis that appears to lie in an abnormal location (normally, the head of the epididymis lies at the superior pole of the testicle and its body extends posterolateral along the testicle). Comparison with the other testicle may help with this determination. Normal position does not rule out torsion, however, as the testicle may have rotated a full 360°, or swelling can make accurate assessment of the position difficult.
2. Assess for swelling and tenderness. Torsion, orchitis, and epididymitis all develop swelling and tenderness soon after onset. The swelling often obscures normal anatomy.
3. Determine location of mass. Appendices of the epididymis and testicle can extend from the superior pole of either structure. Spermatocele is most commonly found superior and posterior to the testicle. Varicocele occurs in a similar location, most commonly on the left side. In epididymitis, the epididymis is usually diffusely swollen, which makes it difficult to distinguish epididymis from testicle.
4. Assess the consistency of the mass. A varicocele typically has the consistency of a bag of worms. Hydrocele and spermatocele usually have a cystic consistency. Hydrocele can become tenser as the day progresses (because of the dependent position).
B. Assess the cremasteric reflex. When the inner thigh is lightly stroked, the testicle on that side should rise noticeably. Absence of this reflex suggests torsion of the testicle (3).
C. Elevate the testicle. This usually relieves the pain of epididymitis but not of torsion (3).
D. Transilluminate the mass. Hydrocele and spermatocele will transilluminate.
E. Examine the patient in both the supine and standing positions. Hernias and varicocele usually become more prominent on standing. Have the patient perform the Valsalva maneuver while standing, which may further accentuate these findings.
F. General examination. Tumors can be associated with metastases or gynecomastia (Chapter 14.2).
Testing
Either radioisotope scans or color Doppler ultrasound can be used to confirm or rule out testicular torsion. Specificities of 95% and 97% are reported (2). False-negative results do occur, however, producing lower sensitivities (86% and 80%, respectively) (2). In this series, most false-negative results occurred either in cases of prolonged torsion in which the testicles were no longer salvageable or in cases of intermittent torsion. Ultrasound can be helpful in differentiating some masses (e.g., hydrocele from solid mass, testicular from extratesticular). However, ultrasound showed a disappointing ability to differentiate malignant from benign masses in children (4). Aspiration of a spermatocele usually reveals dead sperm (1). Pyuria is almost always present in epididymitis, but it has also been found in up to 27% of patients with torsion ( >five white blood cells per high power field) (5). Similarly, leukocytosis suggests an infectious cause but it has also been found in 33% of patients with torsion (5).
Diagnostic assessment
Each type of scrotal mass has a typical presentation, and most can be readily diagnosed based on history and physical examination. However, considerable overlap is seen in the presentation and laboratory or imaging studies of these conditions, which makes establishing a diagnosis challenging in some cases. If the diagnosis of testicular torsion cannot be rapidly and confidently excluded, emergent referral is strongly recommended. If testicular torsion is not suspected but a diagnosis is not clear after the history, physical examination, and appropriate studies, less urgent consultation is recommended.
References
1. Junnila J, Lassen P. Testicular masses. Am Fam Physician 1998;57:685–692.
2. Lewis AG, Bukowski TP, Jarvis PD. Evaluation of acute scrotum in the emergency department. J Pediatr Surg 1995;30:277–282.
3. Son KA, Koff SA. Evaluation and management of the acute scrotum. Prim Care 1985;6:637–646.
4. Aragona F, Pescatori E, Talenti E. Painless scrotal masses in the pediatric population: prevalence and age distribution of different pathological conditions—a 10-year retrospective multicenter study. J Urol 1996;155:1424–1426.
5. Kattan S. Spermatic cord torsion in adults. Scand J Urol Nephrol 1994;28:277–279.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Breast Mass/Discharge:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Breast Mass: Breast lumps should be approached with a high index of suspicion for breast cancer, as approximately 20% of solitary or dominant breast masses are breast cancers. The physical examination is an important part of the diagnostic “triple test,” which includes mammography and fine needle aspiration cytology. When all three are positive, 99.4% have breast cancer. When all three tests suggest a benign lesion, only 0.7% have breast cancer.
Screening clinical breast examination detects approximately 50% of breast cancers. There is some but not total overlap with mammography; about 10% of screen-detected cancers are detected by physical examination and missed by mammography, while about 40% are detected by mammography and missed by physical examination. Techniques which increase the sensitivity of the examination include flattening of the breast against the chest wall (arm overhead), circular motions using the pads of the fingers, and spending greater time with the examination.
Cyclical pain and tenderness are usually due to fibrocystic disease. Although breast cancer can present with pain, it is often atypical and there is usually no tenderness. Characteristics of pain with alternative diagnoses include the following: heavy or full of milk (fibrocystic), sharp and radiating (radiculitis), itching, burning, drawing (duct ectasia), burning and stinging (mastodynia), sore, bruised, stabbing (trauma), throbbing (infectious), aching, and locally tender (costochondritis). Benign cysts are more prominent premenstrually and become smaller during the follicular phase of the menstrual cycle. Palpation characteristics suggestive of cancer include a mass that is firm, has indistinct borders, and has attachments to the skin or deep fascia. Dimpling of the skin, retraction of the nipple, bloody discharge from the nipple, and axillary nodal enlargement are all important clues to breast cancer.
Breast Discharge: Galactorrhea occurs when high levels of prolactin act upon a breast primed by estrogen and progesterone. Therefore, it is extremely rare in men unless there is a feminizing state. Milky discharge can usually be visually differentiated from a serous or bloody discharge. If confirmation is needed, microscopic examination for oval fat bodies (or use of Sudan stain) can be performed.
Bloody discharge is due to an ductal carcinoma (in situ or invasive) in one third of patients, a bleeding intraductal papilloma in another third, and fibrocystic breasts with an intraductal component (e.g. ductal ectasia, intraductal hyperplasia) in the remainder. All require further evaluation. When expressed by exam, discharge coming from one duct is more worrisome than discharge from multiple ducts. Bilateral multiductal discharge that is guaiac negative is usually benign regardless of color (milky, brown, green, yellow, blue, or clear), and due to an endocrine or physiologic process.
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Source: Field Guide to Bedside Diagnosis, 2007
Nipple retraction:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Carefully examine both nipples and breasts with the patient sitting upright with her arms at her sides, with her hands pressing on her hips, and with her arms overhead; and with the patient leaning forward so her breasts hang. Look for redness, excoriation, and discharge; nipple flattening and deviation; and breast asymmetry, dimpling, or contour differences. (See Differentiating nipple retraction from inversion.)
Try to evert the nipple by gently squeezing the areola. With the patient in a supine position, palpate both breasts for lumps, especially beneath the areola. Mold breast skin over the lump or gently pull it up toward the clavicle, looking for accentuated nipple retraction. Also, palpate axillary lymph nodes.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Breast nodule:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Perform a thorough breast examination. Pay special attention to the upper outer quadrant of each breast, where one-half of the ductal tissue is located. This is the most common site of malignant breast tumors.
Carefully palpate a suspected breast nodule, noting its location, shape, size, consistency, mobility, and delineation. Does the nodule feel soft, rubbery, and elastic or hard? Is it mobile, slipping away from your fingers as you palpate it, or firmly fixed to adjacent tissue? Does the nodule seem to limit the mobility of the entire breast? Note the nodule’s delineation. Are the borders clearly defined or indefinite? Does the area feel more like a hardness or diffuse induration than a nodule with definite borders?
Do you feel one nodule or several small ones? Is the shape round, oval, lobular, or irregular? Inspect and palpate the skin over the nodule for warmth, redness, and edema. Palpate the lymph nodes of the breast and axilla for enlargement.
Observe the contour of the breasts, looking for asymmetry and irregularities. Be alert for signs of retraction, such as skin dimpling and nipple deviation, retraction, or flattening. (To exaggerate dimpling, have your patient raise her arms over her head or press her hands against her hips.) Gently pull the breast skin toward the clavicle. Is dimpling evident? Mold the breast skin and again observe the area for dimpling.
Be alert for a nipple discharge that’s spontaneous, unilateral, and nonmilky (serous, bloody, or purulent). Be careful not to confuse it with the grayish discharge that can be elicited from the nipples of a woman who has been pregnant.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Nipple retraction:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient when she first noticed the nipple retraction. Has she experienced other nipple changes, such as itching, discoloration, discharge, or excoriation? Has she noticed breast pain, lumps, redness, swelling, or warmth? Has she had a fever? Obtain a history, noting risk factors of breast cancer, such as a family history or previous malignancy.
Carefully examine both nipples and breasts with the patient sitting upright with her arms at her sides; with her hands pressing on her hips; with her arms overhead; and leaning forward so her breasts hang. Look for redness, excoriation, and discharge; nipple flattening and deviation; and breast asymmetry, dimpling, or contour differences. (See Differentiating nipple retraction from inversion.)
Try to evert the nipple by gently squeezing the areola. With the patient in a supine position, palpate both breasts for lumps, especially beneath the areola. Mold breast skin over the lump or gently pull it up toward the clavicle, looking for accentuated nipple retraction. Also, palpate axillary lymph nodes.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Breast nodule [Breast lump]:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient reports a lump, ask her how and when she discovered it. Does the size and tenderness of the lump vary with her menstrual cycle? Has the lump changed since she first noticed it? Has she noticed other breast signs, such as a change in breast shape, size, or contour; a discharge; or nipple changes?
Is she breast-feeding? Does she have fever, chills, fatigue, or other flulike signs or symptoms? Ask her to describe any pain or tenderness associated with the lump. Is the pain in one breast only? Has she sustained recent trauma to the breast?
Explore the patient's medical and family history for factors that increase her risk of breast cancer. These include having a mother or sister with breast cancer or having a history of cancer, especially cancer in the other breast. Other risk factors include nulliparity and a first pregnancy after age 30.
Next, perform a thorough breast examination. Pay special attention to the upper outer quadrant of each breast, where one-half of the ductal tissue is located. This is the most common site of malignant breast tumors.
Carefully palpate a suspected breast nodule, noting its location, shape, size, consistency, mobility, and delineation. Does the nodule feel soft, rubbery, and elastic or hard? Is it mobile, slipping away from your fingers as you palpate it, or firmly fixed to adjacent tissue? Does the nodule seem to limit the mobility of the entire breast? Note the nodule's delineation. Are the borders clearly defined or indefinite? Does the area feel more like a hardness or diffuse induration than a nodule with definite borders?
Do you feel one nodule or several small ones? Is the shape round, oval, lobular, or irregular? Inspect and palpate the skin over the nodule for warmth, redness, and edema. Palpate the lymph nodes of the breast and axilla for enlargement.
Observe the contour of the breasts, looking for asymmetry and irregularities. Be alert for signs of retraction, such as skin dimpling and nipple deviation, retraction, or flattening. (To exaggerate dimpling, have your patient raise her arms over her head or press her hands against her hips.) Gently pull the breast skin toward the clavicle. Is dimpling evident? Mold the breast skin and again observe the area for dimpling.
Be alert for a nipple discharge that's spontaneous, unilateral, and nonmilky (for example, serous, bloody, or purulent). Be careful not to confuse it with the grayish discharge that can be elicited from the nipples of a woman who has been pregnant.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
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