CASE: ACUTE BREAST ISSUE
Adele is a 60yo Caucasian female who comes into triage with a complaint of finding a lump in her breast this morning in the
shower. She is accompanied by her husband. It is Sunday morning in a small ED where there are General Surgery on-call
consultation, limited radiology services and 24-hr onsite laboratory services available.
ABCs are intact. Adele reports finding a lump in her left breast this morning during her shower. This is the first self-exam she
has done after reading an article in a woman’s magazine last night. She says she feels well otherwise, but is worried it might
be cancer. Adele denies signs or symptoms of hemodynamic instability. She has no systemic symptoms, but appears
anxious.
She has been postmenopausal for 10 years and is on hormone replacement therapy. She reports no vaginal bleeding. Adele
screens negative for violence or trauma.
VS: T 97.8, HR 88, BP 150/80, RR 20, 98% on room air
Pain: 2/10, slightly tender to touch over left breast lump, and has not taken any pain medication
Adele was placed in a private non-monitored treatment room and changed into a gown. Her husband prefers to remain in the
waiting room. On your initial assessment, you note an older woman, sitting on the edge of the gurney in no acute distress, but
appears somewhat anxious. On additional questioning, she describes her left breast as having no nipple discharge or skin
changes. There are no problems with her right breast. She has never had a problem with her breasts before. She is G2P2
(both vaginal deliveries), no personal history of ovarian or breast cancer, but her sister has recently diagnosed ovarian cancer.
She has no medical problems and takes medications as prescribed.
She lives with her husband of 36 years in a loving relationship. Children and grandchildren live nearby. She feels she has
good social support. Came by herself because she didn’t want to worry her family. Reveals that she tends to be on the
anxious side, especially related to health issues. No history of SI.
Medications: conjugated estrogens/medroxyprogesterone (0.625mg/5mg), MVI, acetaminophen prn. Allergies: latex.
Physical exam deferred to provider with female chaperone.
VS reassessment reveals
HR 80, BP135/72, RR18, 99% on RA
Appropriate questions to ask for breast mass history:
1. Mass characteristics – onset, location, size, pain?
2. Skin changes, nipple discharge?
3. Previous history of breast mass? Breast biopsy or surgery?
4. Problems with contralateral breast?
5. Systemic symptoms such as weight loss, night sweats, lymph node enlargement?
6. Any recent breast injury?
7. Last provider breast exam?
8. Last mammogram or ultrasound? Ever abnormal result?
9. Family history of breast or ovarian cancer?
10. LMP? Any post-menopausal bleeding?
While the provider is assessing Adele, the female nurse is adjusting workload to serve as the chaperone.
Adele reconfirms with the provider she found a lump in her left breast this morning in the shower while doing her first breast
exam. She says the lump is in the upper outer part of her breast, feels like a small firm grape and is a little tender if pushed
really hard. ROS is confirmed from nurse assessment. Adele denies recent injury. She has never had a mass, breast
procedure nor abnormal mammogram. She has had breast exam done by her provider during her annual checkups, the last of
which was 2 years ago. Her last mammogram was about 5 years ago and was normal.
She reiterates no past medical nor surgical history, but reports again about getting nervous around doctors and about health
issues. She denies known hypertension. LMP was 10yrs ago; no vaginal bleeding since. Family history and social are
reviewed as per nurse assessment.
Female chaperone is present. Adele has given verbal consent for breast exam, exam steps have been described and privacy
has been attended to.
Physical exam (provide elements requested)
GEN: well-nourished, seems mildly anxious otherwise no distress
HEENT: no conjunctival pallor, moist mucous membranes
PULM: CTAB
CV: regular rate and rhythm, no murmur/rubs/gallops
ABD: soft, non-distended, non-tender
BREAST:
Inspection: normal appearance bilaterally, symmetric, no skin changes noted
Palpation: 2cm, firm, immobile, slightly tender to deep palpation mass with ill-defined border noted in the upper outer quadrant
of the left breast at 2 o’clock position, 3 fingerbreadths from areola. No axillary/supraclavicular lymph nodes appreciated.
NEURO: non-focal, GCS-15
After consultation with the General Surgeon, it was agreed that Adele needed to have a diagnostic mammogram with
ultrasound and then an expedited appointment with General Surgery for possible biopsy of the palpable mass. The Primary
Care Provider and WVPM/breast care coordinator were included as additional signers to the ED encounter note to facilitate
the mammogram. Additionally, phone messages were left with both the PCP and WVPM/breast care coordinator.
VS Reassessment reveals
HR 82, BP134/76, RR16
Adele wanted her husband present in the ED treatment room. She was made aware of the need for a mammogram with
ultrasound in the near future and would be contacted by the PCP/PACT team or WVPM/breast care coordinator the following
day to arrange getting this scheduled. She was aware of the need for General Surgery evaluation after the mammogram for
possible biopsy. It was reiterated that follow-up be done in a timely manner. Adele’s husband was now present and she
remained calm throughout the encounter. All of her and her husband’s questions were answered as best as possible.
Adele was given emotional support by both the nurse and provider to help reduce her anxiety. She was instructed to return to
the ED if the mass increased, pain increased, or any skin changes or fever appeared. Adele was given the contact
information for her PCP/PACT team, WVPM/breast care coordinator and General Surgery clinic.
Adele had a diagnostic mammogram with ultrasound within a week showing a spiculated mass in the upper outer quadrant,
BI-RADS category 5 – highly suggestive of malignancy. She followed-up with the General Surgeon specializing in breast
masses the next day where a biopsy was done. Pathology confirmed a malignancy. Adele is now weighing her treatment
options with the help of Surgery, Oncology and her PCP. The breast care coordinator is closely involved in Adele’s care.
KEY LEARNING POINTS – ACUTE BREAST ISSUE
 Utilize proper triage process for acute breast issues
 Appreciate the presence of patient anxiety that often accompanies the finding of a breast mass and offer
reassurance, support and compassionate care throughout the ED encounter
 Ensure privacy, dignity, security, comfort and the use of an appropriate female chaperone when examining female
breasts
 Emergency providers should perform a thorough clinical breast exam in the setting of an acute breast issue
 Appropriate consultation and facilitating timely post-ED discharge follow-up are important when an acute breast mass
has been identified
 Emergency staff should be aware of who their facility’s WVPM and breast care coordinator are as a way to ensure
and coordinate continuity of care in the setting of a newly found breast mass
 The plan of care should be effectively communicated to patients and family as well as among ED staff throughout the
encounter