Diagnostic Workup for Breast Conditions

Diagnostic Workup for Breast Conditions

• Clinical imaging evaluates masses and other breast abnormalities, guiding biopsies.
• Ultrasound is more sensitive than mammograms but less specific, more expensive, and has a higher false positive rate.
• Tissue sampling is performed if suspicious findings are detected during evaluation, regardless of findings at other stages, due to the imperfect sensitivity and specificity of clinical breast exams (CBE) and imaging.
• Women over 40 should have a mammogram followed by an ultrasound; women aged 30-39 should err on the side of caution by having both a mammogram and ultrasound.
• Women under 30 should have an ultrasound or MRI (if family history present).
• MRI is not routinely recommended unless there is follow-up on biopsy-proven cancer or some other indication.
• The GAIL model is a calculator tool for assessing a woman's 5-year breast cancer risk using personal medical history, reproductive history, and first-degree relative history.

Concerning Signs of Breast Cancer

• Nipple discharge, inversion or discoloration.
• Skin changes, asymmetry, or skin changes.
• Documentation of mass should include location, size, shape, consistency, tenderness, mobility, and retraction/dimpling.
• Common breast cancers include: ductal/lobular carcinoma (painless lump, typically irregular and fixed), inflammatory breast cancer (redness, swelling, no mass, aggressive), and Paget disease (crusty nipple, areola itching, steroid resistant).
• Other common breast findings include: fibrocystic changes (cyclical cysts with menses), fibroadenoma (firm, mobile, round, painless), fat necrosis (post-injury), intraductal papillomas (nipple discharge), duct ectasia (benign discharge), galactorrhea (unrelated to childbearing), and mastitis (infection, swelling, tenderness, redness).
• Fibroadenoma- firm, mobile, painless, smooth borders.
• Breast cyst- fluid-filled sacs, benign, more common in 40s, painless or tender.
• Fibrocystic changes- benign, typically bilateral.
• Lipoma or other benign soft tissue mass- soft, mobile, not too well-defined.
• Screening guidelines are provided for average-risk women.

Exam 1

• Anchoring bias occurs when a clinician over-relies on the first piece of information received.
• Screening tests are used in asymptomatic patients to detect diseases early.
• Diseases contributing to harm when thinking about diagnostic error include vascular, infection, and cancer.
• Epidemiology is the study of disease distribution in populations.
• When assessing a new patient, knowing the differential diagnosis(es) relies on patient history and physical examination (both data points).
• Diagnostic testing criteria includes sensitivity which measures true positive results among all positive cases.
• A high value test is appropriate when testing a 68-year-old male patient who is up to date on colonoscopies.
• Imaging to evaluate soft tissues includes MRI.
• Ultrasound is the first line diagnostic for a 25-year-old patient with a palpable breast mass.
• Diagnostic mammogram is prioritized (step one) if a 45-year-old woman has a palpable breast mass.
• Thyroid function can be evaluated with a TSH test.
• To evaluate an unexplained lymphadenopathy, complete blood count is the first diagnostic step.

Additional Details

• Imaging studies include X-ray, CT scan, MRI and ultrasound.
• Possible screening tests: Colonoscopy, Cervical (HPV), CT Scan, and Mammogram.

Medical History

• Hypertension, hyperlipidemia, tobacco use disorder.
• Symptoms are a persistent and worsening cough, shortness of breath (especially with exertion), and occasional white sputum.

Physical Examination

• Vital signs: BP 135/85 mmHg, HR 90 bpm, RR 22 breaths/min, O2 saturation 92% on room air.

Specific Findings

• Lung exam: bilateral wheezing, decreased breath sounds at the bases, no dullness to percussion.
• Cardiac exam: regular rhythm, no murmurs.
• Other findings: mildly enlarged lymph nodes in the cervical region.
• Differential diagnoses from different organ systems or mechanisms (pathophysiology) are recommended.