Res 2 DSL tutorial

Breast Problems

This edition of the DSL contains several shorter patient case histories
Read your textbook section on breast examination. Inspection from the front, with the
patient sitting on the edge of the bed must not be rushed.
With appropriate supervision and chaperone carry out the examination on at least two
breast patients in the ward during Res 2. If you do not do this you will be marked down!
The breast is a common site of serious pathology and examination of the female patient is
not complete unless breast examination is done and documented. Breast patients are
understandably reserved. Women will more readily give consent to a female student who
can ask if a male may join her: no more than one male and two females unless the patient
is very relaxed.
We will run through a number of typical scenarios

Patient 1
A 57 year old woman presents at the breast clinic saying she has noticed a greenish
discharge from the left nipple. On one occasion she had a similar discharge form the right
side. You find no breast mass and the axillae are normal.
What will you ask her? List below

When the woman is examined gentle pressure on the areolar produces the following
findings

Nipple discharge appears like blood

when dabbed on white gauze was dark green

You note that the dark green discharge is from not a single duct but from several.
You test it for blood negative.

What is your diagnosis?

Will you arrange more investigation?
Does the patient need surgery?

Patient 2
The history is similar but this time the patient thinks the discharge is bloody and you
confirm this by dipstick testing. Also the discharge appears to be from a single duct
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There are two main possible diagnoses. What are they?

This is a typical lesion excised from such a patient. Describe it.

This is an intraduct papilloma. Why does it bleed?

How would you manage this patient?

Patient 3
A 28 year old woman, who is breast feeding her baby, presents to her GP complaining of
severe pain in her right breast, fever and feeling very unwell.
When you examine her, this is what you find.

Breast abcess with pointing

The diagnosis is obvious. List below the clinical signs and symptoms of an abscess.

How would you manage this patient?

What is the bacterium involved?
Which antibiotic would you prescribe?

Patient 4
A 17 year old girl comes with a mass in her breast. It is not painful. There is no family
history of breast cancer.
On examination the mass is firm, 2cm in diameter and very mobile. The axilla is normal.
What is your clinical diagnosis?

This is such a lesion excised. How does the appearance differ from cancer?

How will you confirm the diagnosis?

What is your plan for management?

Patient 5
A 35yr old premenopausal lady comes complaining of pain in her breasts.
She says she has had the pain on and off for 5years but it is getting worse. It is worse
before her periods and goes away when her periods finish. Her breasts have become very
lumpy especially at period times and 5 days ago she noticed while showering a lump in
her Right breast which she had never felt before and it is slightly tender.
When you examine her, her breasts are lumpy throughout with marked thickening of the
axillary tail on both sides. In the Right breast there is a discrete 2 cm swelling
which is slightly tender.
What is your working diagnosis at this time? What is the new lump that you feel?
You refer her to the breast clinic. What will be done there?

The surgeon thinks this is a cyst. He cleans the area with a spirit swab and puts a green
needle into the swelling . He aspirates 4 ml of murky green fluid.
Following this the swelling is no longer palpable
What does he tell the patient?

Note the multiplicity of cysts. 30% of women have some degree of this.

What follow up is arranged and does he do any other investigations?

Viewing mammograms is specialized work but we will look at a few simple examples to
give you some understanding of the various changes.

This is fibrocystic disease. Heterogeneous and very diffuse.

This is a normal fatty breast.

This is the spiculation typical of cancer

This is a cancer with suspicious calcifications

Do you understand the importance of multidisciplinary meetings in cancer management?
Write below what you think it means

Patient 7
This is an elderly patient who complains of some soreness of her nipple over the last 6
months

What is the differential diagnosis?

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If you were the GP what would you do?

What would you say to the lady?

Write below your understanding of a screening programme for breast cancer (or any
cancer)

Finally- what is this?

WOK 18/9/2012

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