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Probability diagnosis

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Pregnancy

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Cracked or inflamed nipple

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Cyclical mastalgia:

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  • benign mammary dysplasia

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Serious disorders not to be missed

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Vascular:

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  • acute coronary insufficiency

  • thrombophlebitis (Mondor disease)

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Infection:

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  • mastitis

  • breast abscess

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Cancer:

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  • breast (uncommon presentation)

  • mastitis carcinomatosa

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Pitfalls (often missed)

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Pregnancy

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Chest wall pain (e.g. costochondritis)

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Pectoralis muscle spasm

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Referred pain, esp. thoracic spine

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Bornholm disease (epidemic pleurodynia)

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Herpes zoster

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Mechanical:

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  • bra problems

  • weight change

  • trauma

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Rarities:

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  • hyperprolactinaemia

  • nerve entrapment

  • mammary duct ectasia

  • sclerosing adenosis

  • ankylosing spondylitis

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Masquerades checklist

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Depression

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Drugs (e.g. OCP, HRT, marijuana)

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Spinal dysfunction

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Is the patient trying to tell me something?

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Yes. Fear of malignancy. Consider psychogenic causes.

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Key history

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Relate the pain to the menstrual cycle and determine whether the patient is pregnant or not.

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Key questions:

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  • Could you be pregnant?

  • Is your period on time or overdue?

  • Is the pain in both breasts or only one?

  • Do you have pain before your periods (cyclical mastalgia) or all the time during your cycle (non-cyclical mastalgia)?

  • Do you have pain in your back or where your ribs join your chest bone?

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Key examination

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  • Systematic breast palpation to check for soreness or lumps including regional lymph nodes

  • Underlying chest wall and thoracic spine (T3–T6)

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Key investigations

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  • Pregnancy test

  • Mammography (>40 years) and ultrasound

  • FNA/excision biopsy for lump with localised pain

  • Consider CXR and ECG

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Diagnostic tips

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  • Consider cancer or candida if constant (prickling) breast pain.

  • Consider a rare florid form of breast cancer, ‘mastitis carcinomatosa’, if red, hot area.

  • Watch for abscess if a lactating woman has unilateral breast pain and ‘flu’ symptoms.

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