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Case Study: It’s a Lump, but is it Breast Cancer?

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Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.

Case Study Content allnurses® Certified

Does this woman have breast cancer?

I am so excited about this Case Study because I feel it will be useful to so many of you! Welcome to a new Case Study in which the patient, a 45-yr-old, white, premenopausal woman, presents for her annual exam with a small lump in her breast that has grown in size over the last few weeks.

Case Study: It’s a Lump, but is it Breast Cancer?
If you think you know the correct diagnosis for this Case Study (CSI)...

DO NOT POST ANSWER HERE.

Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below.

Presentation

A 45-yr-old, white, premenopausal woman presents for her annual exam. About 5 weeks ago, she noticed a small, painless lump in the upper outer quadrant of her left breast. “I didn’t think much about it because I’ve had so many lumps – they always pop up when I get my period.” She states that usually the lumps become palpable and bother her about 10 days before her menses, but then they go away. Right now, she is about 4 days from her expected date of menstruation. She is a nonsmoker, nondrinker and denies recreational drug use. She only takes PRN medications occasionally.  She has a supportive partner and two children ages 13 and 17. 

Chief Complaint

“My breasts have always been cystic, but I found a new lump in my left breast that has me worried.”

History of Present Illness

She has no history of dysmenorrhea, but the lump hasn’t gone away and seems to have grown in size. She denies tenderness, pain, nipple discharge and skin changes in her breasts and no masses in the axillary region of her left arm are found. She states that she practices breast self-exams, “but not as often as I should.” She has never had a mammogram. Several years ago, she had a breast biopsy that was consistent with fibrocystic changes. Her only Pap smear was done two years ago, and the result was normal.

Past Medical History

Her medical history is unremarkable except for a broken arm in grade school. Menarche was at age 11. Her first pregnancy was at age 27 and her second at age 32 – both pregnancies were full term and deliveries were vaginal with no complications.

Family History

Paternal grandmother diagnosed with breast cancer before menopause at age 48. Mother died of breast cancer at age 75, though the cancer was diagnosed when she was 45. She had two periods of long-term remission, but it recurred again 16 years ago. Her father is 88 and has HTN, history of stroke, type 2 DM and Alzheimer’s disease. He lives in a nursing home.

Social History

Drinks 6-8 cups of coffee weekly, exercises 3x weekly, has a degree in communications from a local college, but she now works as a personal life coach.

Allergies

Latex and adhesive tape cause a rash.

Questions

What are the possible reasons for this lump? Is it just another cyst? How many reasons for breast lumps can you come up with off the top of your head? How many risk factors for breast cancer can you spot? What labs do you want? What other diagnostic tests should we run?

REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is also a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes on the computer. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com.

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5 Comment(s)

sirI, MSN, APRN, NP

Specializes in Education, FP, LNC, Forensics, ED, OB. Has 30 years experience.

REMEMBER:

If you think you know the correct diagnosis for this Case Study (CSI), DO NOT POST YOUR ANSWER(S) HERE.

Instead, post your answer in the ADMIN HELP DESK. Members have been entering their guesses and rationales. 👍 We don't want to spoil it for others who are late in joining us.

In a few days, after SafetyNurse1968 posts the diagnosis, the Admins will announce the names of those members who correctly identified the problem.

You CAN post questions, request more information and post comments below.  BUT ... Do NOT post your diagnosis guess below.

GOOD LUCK everyone!

EDNURSE20, BSN

Specializes in ED, med-surg, peri op. Has 4 years experience.

Reasons for breast lumps are essentially any hormonal changes like menopause, pregnancy, contraception, Breast feeding or periods. 

Non cancerous lumps could be cysts, lipoma or fibrocystic changes  

signs of cancer I picked up on, other than the lump, are family hx, the pt age and early onset of mensuration. I’m sure there are more. 

for the examination:

- as for the breast themselves, no pain or nipple changes but is there a rash? Or any change to size/shape?

- I would do a pregnancy testing, unlikely but to rule it out

- menopause is more likely, regular menses? Hot flashes? Wt gain? Mood changes? 

- bloods, fbc, crp, fsh, tsh, u+e’s, hb1ac, lipids

- mammogram. 

Considering the pt age and family hx alone, I would be concerned about breast ca. But I feel like for a case study this is to obvious. 

mom_e_bizcut, LPN

Specializes in Jack of all trades, master of...a few ;). Has 24 years experience.

How about the physical exam? Is the lump soft and pliable, can it be moved around? A mammogram will most certainly be ordered either way, but if the lump is hard and immovable it may be a more immediate appointment or they could possibly do an ultrasound right there depending on the resources available at the office. Any recent illness or allergic reactions? Blood work may be needed as well assuming standard tests prior to test for change in BRCA1 or BRCA2 genes, but with family history I guess that could be an earlier option.

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.

Thank you so much for your questions and comments! Here is the first update:

Finding a lump in your breast can be frightening — but although breast cancer is the most common cancer found in women, most breast lumps are not cancer. In fact, more than 80 percent of them end up being benign

Breast lumps can be caused by:

  • Breast cancer
  • Breast cysts (fluid-filled sacs in breast tissue that are usually benign)
  • Fibroadenoma (a solid, benign mass most common in young women)
  • Fibrocystic breasts (lumpy or rope-like breast tissue)
  • Galactocele (a milk-filled cyst that's usually harmless)
  • Injury or trauma to the breast
  • Intraductal papilloma (a benign, wartlike growth in a milk duct)
  • Lipoma (a slow-growing, doughy mass that's usually harmless)
  • Mastitis (an infection in breast tissue that most commonly affects women who are breast-feeding)

Risk Factors

Most breast cancers are found in women 50 years or older. Most of us have some risk factors, but most women don’t get breast cancer. Risk factors include getting older, early menstruation and menopause after age 55

Other risk factors for breast cancer:

  • close relatives who were diagnosed with breast cancer before the age of 45 – especially if more than one relative was diagnosed
  • changes in BRCA1 and BRCA 2 genes
  • Ashkenazi Jewish heritage
  • radiation therapy to the breast or chest during childhood
  • history of breast cancer or other health problems like in situ carcinomas, atypical ductal hyperplasia or atypical lobular hyperplasia
  • dense breasts on a mammogram
  • lack of physical activity, being overweight or obese after menopause, taking hormones, first pregnancy after 30, not breastfeeding, never having a full-term pregnancy, drinking alcohol and smoking

Review of Systems: only abnormal values presented

Lymph nodes/neck: one movable, firm, non-tender axillary lymph node of approximately 1.5 cm palpated under left arm

Breast exam:

  • Symmetric breasts
  • No dimpling or erosion of skin, no nipple retraction or discharge, no erythema, discoloration or swelling
  • Multiple, diffuse, small (0.4-1.2 cm) mobile, apparently cystic lesions palpable throughout both breasts.
  • One 2 cm mass palpated in upper outer quadrant of left breast, mass is firm and not fixed to the chest wall and is not tender to the touch.

Vital signs:

  • BP 136/85 sitting, RA
  • HR 70
  • RR 15
  • T 98.3oF
  • HT 5’ 6”
  • WT 135 lbs

Laboratory Test Results:

  • Na 139 meg/L (135-145)
  • K 4.1 meq/L (3.5-5)
  • Cl 107 (101-112)
  • HCO3 24 mg/dL (22-32)
  • BUN 9 mg/dL (8-20)
  • Cr 1.0 mg/dL (0.6-1.2)
  • Glu fasting 88 mg/dL (60-110)
  • Hb 14.3 g/dL females (12-15.5)
  • Hct 37.5% females (35-45%)
  • Plt 420,000 cu/mm (150,000-450,000)
  • WBC 8.0 x 103/mm3 (4,800- 10,800)
  • Neutros 60% (57-67)
  • Lymphs 31% (25-33)
  • Eos 3% (1-4)
  • Monos 6% (3-7)
  • AST 38 IU/L (0-35)
  • ALT 30 IU/L (7-56)
  • Alk phos 97 IU/L
  • Albumin 4.0 g/dL (3.4-4.7)

Bilateral mammogram:  There were three 1.0-1.5 cm masses distributed diffusely throughout the right breast and four 0.5-1,0 cm masses in the left breast. There also was a 2.1 cm x 3.0 cm x 3.1 cm mass with irregular borders within the upper outer quadrant of the left breast. Associated with the suspicious lesion was diffuse skin thickening and an enlarged axillary lymph node of approximately 1.5 cm. Seven Y-shaped microcalcifications extending to the nipple were seen in the left breast. There is some evidence of extension of the abnormal mass into the pectoral muscle.

 

Can you identify at least six clinical manifestations that might support a diagnosis of breast cancer?