Breast Mass
Age: years old
Gender: female
HISTORY:
Presents with a - history of breast lump
Location of the lump:
Consistency:
Changes in size or shape:
Surface:
with pain
Worsening factors:
Alleviating factors: ,
Associated symptoms: *Try using right-click for negatives*
, up to °, over
, over ,
Contributing factors:
no history of: ,
no use of: ,
no family history of:
EXAM:
General appearance: ,
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Breasts: , ,
Pelvic: external genitalia , vagina , cervix , uterus , adnexa ,
ASSESSMENT:
DDx: fibrocystic breast changes, breast cancer, fibroadenoma, cyst, intraductal papilloma, mastitis, abscess, fat necrosis, galactocele, duct ectasia, phylloides tumor, lipoma, hamartoma, inflammatory breast cancer, lymphoma, gynecomastia, hormonal changes, trauma-related changes
PLAN:
Investigations:
- Mammogram
- Ultrasound of the breast
- Blood work: , , , , , ,
- Breast biopsy
Treatments:
-
Further care:
- Referral to breast surgeon
- Referral to oncologist
- Referral to genetic counselor
- Follow-up in
- Return if lump grows, changes shape, or if new symptoms develop such as nipple discharge or skin changes
HISTORY: Associated symptoms: EXAM: ASSESSMENT: PLAN: