Makindo Medical Notes

Clinical History

1. Onset and Duration: Determine when the pain began and if it is acute, chronic, or cyclical (related to menstrual cycles).
2. Location and Nature of Pain:
   • Is it localized to a specific area or generalized in one or both breasts?
   • Is the pain dull, sharp, burning, or throbbing?
3. Timing and Pattern:
   • Does it correlate with the menstrual cycle (cyclical mastalgia)?
   • Is it persistent or intermittent?
4. Associated Symptoms:
   • Breast lump, swelling, or nipple discharge
   • Redness or warmth over the breast
5. Risk Factors and Medical History:
   • Family history of breast cancer
   • Previous history of breast issues, including cysts or fibroadenomas
   • Hormonal factors (e.g., use of contraceptives, hormone replacement therapy)
6. Medication History: Review medications that may affect breast tissue, including:
   • Hormonal therapies (e.g., oral contraceptives)
   • Antidepressants (e.g., SSRIs)
   • Antihypertensives
7. Lifestyle Factors:
   • Diet, especially caffeine intake
   • Use of tobacco or alcohol
   • Level of physical activity or recent trauma

2. Physical Examination

1. General Inspection: Look for signs of asymmetry, skin changes, or visible masses.
2. Palpation:
   • Palpate each quadrant of the breast and the axillary regions for tenderness, lumps, or nodules.
   • Note the location, size, and consistency of any masses.
3. Examine for Skin and Nipple Changes: Look for dimpling, retraction, or nipple discharge.
4. Lymph Node Examination: Palpate axillary and supraclavicular nodes to assess for any enlargement.

Investigations

1. Mammography: Recommended especially for women over 40 or if a mass is identified.
2. Ultrasound: Useful for assessing cystic versus solid lesions, particularly in younger women.
3. Breast MRI: Considered if there is a high index of suspicion for malignancy or if imaging findings are inconclusive.
4. Hormone Levels: If hormonal imbalances are suspected, assess estrogen and progesterone levels.
5. Fine-Needle Aspiration or Biopsy: For definitive diagnosis if a suspicious mass is present.

Possible Causes of Breast Tenderness/Pain

• Cyclical Mastalgia: Related to hormonal changes during the menstrual cycle; typically bilateral and generalized.
• Non-Cyclical Mastalgia: Persistent or localized pain not associated with menstrual cycle changes, often due to:
  • Breast cysts
  • Fibroadenomas
  • Infections or mastitis
• Hormonal Factors:
  • Pregnancy
  • Hormone replacement therapy
  • Oral contraceptives
• Medication-Induced Pain: Certain drugs, including hormonal therapies and SSRIs.
• Costochondritis: Inflammation of the costal cartilage can cause pain that mimics breast pain.
• Trauma or Injury: Direct trauma to the breast or chest wall strain.
• Breast Cancer: Rarely presents with pain but should be considered in unexplained cases, especially if other symptoms are present.

Management

1. Reassurance and Monitoring: Reassure patients with benign findings and encourage self-examination and monitoring.
2. Symptomatic Relief:
   • Warm compresses
   • Over-the-counter pain relievers (e.g., acetaminophen, NSAIDs)
   • Supportive bra to minimize movement-related pain
3. Modify Lifestyle Factors:
   • Reduce caffeine intake
   • Limit tobacco and alcohol use
4. Consider Hormonal Therapy Adjustments: If on HRT or contraceptives, adjustments may be needed.
5. Referral: Consider referring to a breast specialist if a suspicious mass is present or pain persists despite treatment.

Clinical History

• Presenting Symptoms: Identify the chief complaint, onset, duration, severity, and associated symptoms.
• History of Present Illness (HPI): Detailed account of symptoms, including any exacerbating or relieving factors.
• Past Medical History (PMH): Any pre-existing conditions, past surgeries, and chronic diseases.
• Medication History: Current medications, over-the-counter drugs, and supplements.
• Family History: Genetic predispositions and family history of relevant diseases.
• Social History: Lifestyle factors, including smoking, alcohol use, diet, and exercise.

Physical Examination

• General Observation: Assess overall appearance, alertness, and discomfort level.
• Vital Signs: Measure blood pressure, heart rate, temperature, respiratory rate, and oxygen saturation.
• Systematic Examination:
  • Head-to-toe approach covering all systems (cardiovascular, respiratory, neurological, gastrointestinal, musculoskeletal, etc.).
  • Special focus on areas corresponding to the patient’s complaints.

Differential Diagnosis

Cause	Tests & Investigations	Management Plan
Cyclical Mastalgia (Hormonal)	Clinical history (pain related to the menstrual cycle) Breast examination to rule out lumps or abnormalities Mammography or ultrasound if indicated (e.g., age >40 or abnormal findings)	Reassurance (normal variant) Supportive bras Consider NSAIDs or paracetamol for pain relief Evening primrose oil or vitamin E supplements (evidence is limited) Consider hormonal treatment (e.g., oral contraceptives or danazol) if severe
Non-Cyclical Mastalgia	Clinical history (pain not related to the menstrual cycle) Breast examination for lumps or tenderness Mammogram or ultrasound to exclude underlying pathology	Reassurance if no underlying cause is found Topical NSAIDs for localized pain Referral to a breast clinic if imaging is abnormal
Mastitis or Breast Abscess	Clinical history and examination (tender, swollen, warm breast, fever) Ultrasound if abscess is suspected Breast milk culture (if breastfeeding and bacterial infection suspected)	Antibiotic therapy (e.g., flucloxacillin for staphylococcal infection) Incision and drainage of abscess if necessary Encourage continued breastfeeding or milk expression Pain relief with paracetamol or ibuprofen
Fibrocystic Breast Changes	Breast examination (palpable lumps, often tender) Ultrasound or mammogram if a suspicious lump is identified Aspiration of cystic lesions for diagnosis and symptom relief	Reassurance (benign condition) Warm compresses for pain relief NSAIDs for pain management Avoid caffeine (anecdotal evidence of improvement)
Breast Trauma	Clinical history (recent trauma or injury to the breast) Breast examination for signs of haematoma or fat necrosis Ultrasound or mammogram if abnormal findings or persistent symptoms	Pain relief (NSAIDs or paracetamol) Reassurance that most haematomas resolve spontaneously Follow-up if persistent pain or lump develops
Breast Cancer (Rare Cause of Mastalgia)	Thorough breast examination (look for lumps, skin changes, nipple retraction) Mammography and/or ultrasound if any suspicious findings Core biopsy or fine-needle aspiration for definitive diagnosis	Urgent referral to a breast surgeon or oncologist if cancer is suspected Management will depend on the stage and type of cancer (surgery, chemotherapy, radiation, hormonal therapy)
Medication-Induced Mastalgia	Review of medications (e.g., hormonal therapy, antidepressants) Breast examination to rule out other causes	Consider switching medications if possible Symptomatic treatment with NSAIDs or paracetamol Discuss risks and benefits if hormone replacement therapy (HRT) or contraceptive is the cause

Diagnostic Tests and Investigations

• Laboratory Tests: Blood tests, urine analysis, cultures, and specific markers (e.g., TFTs, LFTs).
• Imaging Studies: X-rays, ultrasound, CT, MRI, or specialized scans as needed.
• Specialized Tests: ECG, echocardiogram, endoscopy, or biopsies depending on the suspected condition.

Diagnosis and Plan

• Diagnosis: Based on the clinical assessment and investigations, establish a diagnosis or narrow down the differential.
• Management Plan: Outline the treatment options, follow-up care, and referrals if necessary.
• Patient Education: Discuss the diagnosis, treatment options, and any lifestyle changes with the patient.