Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Junior Doctor working in General Practice. Your next patient is Taylor Smith - a 30-year-old female presenting with tenderness in the breast. Please take a history and perform an appropriate examination.
Patient History:
Taylor Smith, a 30-year-old female, HR manager
Over the last few days, you have been experiencing tenderness and redness in your right breast around the nipple region. The pain is constant and is like a burning sensation. This is slowly getting worse. You have tried paracetamol which only helped a bit. Touching it can make the pain worse. No pain radiation. You rate the pain currently 3/10. The area does feel firm and warm to the touch. The breast or the nipple is not itchy or cracked/ flaky. You do have some discharge from the right breast, but you are not sure if this is milk, as you are currently breastfeeding your baby, Stevie. There's, however, no blood in the discharge. You do feel a bit shivery lately and tired. No recorded temperature. You feel nauseated but no vomiting.
You have not noticed any lumps. No weight loss. No night sweats. No previous injury to the breast. Waterwork is normal. The bowel is working normally. The left breast is asymptomatic.
Ideas, Concerns, Expectations:
You are currently breastfeeding your newly born child, Stevie, since two weeks ago – you are still adjusting to the correct way to feed your child. You are not sure if this is related. You are concerned that the pain makes breastfeeding more difficult and unsure whether to continue. You would like to seek treatment as soon as possible.
Past Medical History:
Nil.
No past surgical history.
Drug History:
Vitamin tablets from the counter.
NKDA
Family History:
No breast problems run in the family.
Social History:
You used to smoke but have stopped since you got pregnant with your first child Stevie. You also stopped drinking alcohol since being pregnant. You live with your husband in an apartment in the city. Independant at home. You work as an HR manager.
Examination Findings:
Erythema in a focal, wedge-shaped area of right breast tissue centrally, which is firm and tender to touch with warmth. It appears to be inflamed. Areola/nipple is normal on inspection and palpation.
Yellow nipple discharge upon squeezing the right nipple (no blood).
No palpable mass or collection. No fluctuant tender lump.
No axillary lymphadenopathy
Differentials:
Mastitis
Breast Abscess
Duct ectasia
Investigations:
Bedside:
Clinical Diagnosis
Observations, including temperature.
Culture and sensitivities for milk sample/ discharge
Bloods:
Consider blood culture and sensitivities
Consider routine blood tests, including FBC, and CRP, for infection
Imaging:
US Breast to rule out breast abscess (usually form a hypoechoic lesion)– especially if the infection does not settle despite a course of antibiotics.
Consider a mammogram to look for underlying lesions after the acute phase.
Special test:
Diagnostic needle aspiration with cytology, culture and sensitivities
Management: