Breast Assessment Case Scenario

Questions
1. Is any treatment or advice appropriate at this time?
2. What education is important to provide to women regarding self-breast examination and when to report a finding to a practitioner?

Karen is a 38-year-old white female in good health presenting to the health clinic with a chief complaint of a small lump in the left breast of approximately 18 months duration. She is being seen by an Advanced Practice Registered Nurse who obtains the following history and physical examination data.
A mammogram was performed in May 2009 and again in August 2010. Both were interpreted as normal. An ultrasound was also performed in May 2009. Karen was informed by her physician that the lump was fibrocystic and benign.
Family History
Father died age 62 from MI; mother and three sisters are healthy.
Social History
Divorced with 2 daughters ages 7 and 5. She is employed as an occupational therapist.
Medical History
Menses at age 12.
Physical Examination
Physical Examination
Vital Signs Blood pressure: 114/74.
Pulse 85.
Respiratory rate 16 per minute.
Temperature 37.0 C.
Weight 160 pounds.
Height 69 inches.
Skin Scar from previous C-sections.
Eyes Pupils equal, round and reactive to light, extra ocular muscles intact.
Ears Tympanic membranes appear to be normal.
Oral Cavity She has good dentition. There are no oral lesions. Posterior pharynx is without erythema.
Neck No lymphadenopathy or masses.
Lungs Clear to auscultation.
Heart Regular rhythm. Rate 85 per minute. No murmurs or gallops.
Abdomen Soft, no palpable organs or masses. Nontender. Liver span is approximately 10 cm by percussion.
Breasts Right breast is without palpable masses, retraction, dimpling, or nipple discharge. 2 cm. firm, non-tender palpable mass noted in the 11 o’clock position of the upper outer quadrant of the breast. When patient leaned forward for breast exam, retraction of the left nipple and breast tissue was noted. No right or left axillary, pectoral or supraclavicular adenopathy noted.
Questions
1. Is any treatment or advice appropriate at this time?
2. What education is important to provide to women regarding self-breast examination and when to report a finding to a practitioner?

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