A 46-year-old Caucasian woman presents to the clinic complaining of breast pain. The patient state the
pain is intermittent, in the right breast, the pain is sharp and has a burning sensation. She rates the pain
as 7/10 at it worst. The patient states the pain sometimes interferes with her sexual activity. She has
tried warm compresses, ibuprofen, and support bras with little improvement. Pt is on oral birth control
pills and takes a daily vitamin.
Soc hx: Pt reports she sometimes eats nutritious meals, but due to her job and family obligations she
does eat fast food frequently. Pt states she is an assistant accountant at a local accounting firm, which
adds to her stress especially at the end of each month and during tax season. She exercises 1-2
times/week by walking around the block. Sometimes the walking causes more pain in her breast. She
drinks socially once or twice a month and has 1-2 glasses of wine at that time. She smokes 2 packs/day
for last 22 yrs. She has tried to quit but has not been successful. Family history non-contributory.
Objective Info
Height 5’6” Wt 155 lbs; BMI 25; 140/78; HR-72/min
• HEENT: Normocephalic, no lumps/lesions
• Neck: supple without adenopathy , no thyromegaly.
• Lungs: Eupneic, CTA-bilaterally
• CV: RRR, no murmurs, rubs or extra sounds noted; 2+ peripheral pulses, no edema noted
• Breast: Macromastia breasts are soft, fibrocystic changes bilaterally noted without masses,
dimpling or discharge, no redness or inflammation noted.
Questions
1. What other information do you need?
2. Describe the most appropriate way to perform the breast exam on this patient.
3. What diagnostic tests would be appropriate for this pt?
4. What are the risk factors for this patient?
5. What other screenings are appropriate for this patient?
6. When would you refer to a breast specialist?
7. What pharmacological and nonpharmacological therapies would you consider for this patient?
