Breast Lump

HISTORY:

‍RightLeftBilateral breast lump for ‍ ‍hoursdays

Location: ‍centralouterinner ‍upperlower

Evolution: ‍no change

Type: ‍hardsoft

Worsening factors: ‍none

Treatments tried: ‍none, ‍effectiveineffective

‍pain

‍nipple discharge

‍nipple retraction

‍swelling

‍redness

‍warmth

‍changes in skin over lump

‍recent breast trauma

‍swollen lymph nodes in armpits

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional



EXAM:

General appearance: ‍well-appearing

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Breasts: -R: ‍normal, -L: ‍normal

Pelvic: vulva ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍no cervical motion tenderness



ASSESSMENT:

‍Breast cyst ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Mammogram

- Ultrasound of the breast

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍glucose, ‍LFTs, ‍CA 15-3, ‍CA 27.29

- Breast biopsy

- ‍Analgesics

- Referral to breast surgeon

- Referral to oncologist

- Referral to genetic counselor

- Follow-up in ‍ ‍weeksmonths

- Return if lump grows, changes shape, or if new symptoms develop such as nipple discharge or skin changes