The document provides guidance on evaluating breast lumps, pain, and nipple discharge. It discusses:
1) Defining breast lumps and assessing risk factors for breast cancer through history, physical exam, imaging and tissue sampling.
2) Evaluating breast pain by differentiating cyclical from non-cyclical pain and considering extramammary sources through history and physical exam.
3) Distinguishing benign from suspicious nipple discharge based on characteristics like spontaneity, color, presence of a mass and laterality obtained through history and physical exam.
Soft tissue sarcomas, treatment (surgical, radiation, chemotherapy)Joseph A. Di Como MD
A PowerPoint presentation for medical professionals regarding soft tissue sarcomas, likely most helpful to surgical residents and medical students. Gist tumors, liposarcomas, retroperitoneal sarcomas extremity, breast sarcoma and vascular sarcomas
Information about Low Anterior Resection by Dr Dhaval Mangukiya.
Details of GOAL of LAR, Margins, Reconstructions, Anal Anastomosis, End to Side Colorectal Anastomosis, Stapler Vs Hand Sewn, Intersphincteric Resection, Colonic J pouch Anastomosis etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Soft tissue sarcomas, treatment (surgical, radiation, chemotherapy)Joseph A. Di Como MD
A PowerPoint presentation for medical professionals regarding soft tissue sarcomas, likely most helpful to surgical residents and medical students. Gist tumors, liposarcomas, retroperitoneal sarcomas extremity, breast sarcoma and vascular sarcomas
Information about Low Anterior Resection by Dr Dhaval Mangukiya.
Details of GOAL of LAR, Margins, Reconstructions, Anal Anastomosis, End to Side Colorectal Anastomosis, Stapler Vs Hand Sewn, Intersphincteric Resection, Colonic J pouch Anastomosis etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Breast disorder is a common presenting complaint in the outpatient setting as well as in secondary and tertiary settings. This presentation focuses on the three most important breast-related complaints which are - breast pain, nipple discharge and breast masses.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
3. DEFINITION
• A breast lump is a growth of tissue that develops within breast.
• A breast mass may be benign or malignant.
• A benign mass may be solid or cystic, whereas a malignant mass is typically solid.
• A cystic mass with solid components (complex cyst) can also be malignant.
• Thorough clinical breast examination, imaging, and tissue sampling are needed for a
definitive diagnosis.
4. RISK FACTORS FOR BREAST CANCER
1. Well-established risk factors
Age 50 or older
Benign breast disease, especially cystic
disease, proliferative types of
hyperplasia, and atypical hyperplasia
Exposure to ionizing radiation
First childbirth after age 20
Higher socioeconomic status
History of breast cancer
History of breast cancer in a first-
degree relative
Hormone therapy
Nulliparity
Obesity (i.e., BMI ≥ 30 kg per m2)
5. CONT…
2. Probable risk factors 3. Possible risk factors
Alcohol consumption Chemical exposure
Did not breastfeed Diet high in fat
Elevated endogenous estrogen levels Diet low in beta carotene,
vitamins A and C
High BMI Diet low in fruits and
Hormonal contraception therapy
Increased mammographic density of breast tissue
Menarche before age 12
Menopause after age 45
Mutations in BRCA 1 and BRCA 2 genes
6. INITIAL EVALUATION
HISTORY
1. Breast lump characteristics 3. Medical and surgical history
Changes in size over time Personal history of breast cancer
Change relative to menstrual cycle Previous breast masses and biopsies
Duration of mass Recent breast trauma or surgery
Pain or swelling Recent radiation therapy or
Redness, fever, or discharge Other exposure to radiation
2. Diet and medications 4. Family history
Current medications History of breast disease
History of hormone therapy Relationship to patient
Relative’s age at onset
7. CONT…
5. Personal characteristics 6. Social history
Age at menarche Radiation and chemical
Age at menopause Smoking
Current age
Current lactation status
History of breastfeeding
Number of children
8. PHYSICAL EXAMINATION
• Includes assessment of both breasts and the chest, axillae, and regional lymphatics.
• In premenopausal women, it is best done the week following menses, when breast
tissue is least engorged.
• With the patient in an upright position, Inspect the breasts:
Noting asymmetry
Nipple discharge
Obvious masses
Skin changes, such as dimpling, inflammation, rashes, and unilateral nipple retraction
or inversion
9. CONT…
• With the patient supine and one arm raised, palpate:
Breast tissue on the raised-arm side in the superficial, intermediate, and deep tissue
planes (i.e., the “triple touch” technique)
Axilla
Supraclavicular area
Neck
Chest wall
• Assessing the size, texture, and location of any masses.
10. CONT…
• Benign masses generally cause no skin change and are smooth, soft to
firm, and mobile, with well-defined margins.
• Diffuse, symmetric thickening, which is common in the upper outer
quadrants, may indicate fibro-cystic changes.
• Malignant masses generally are hard, immobile, and fixed to surrounding
skin and soft tissue, with poorly defined or irregular margins.
• Mobile or nonfixed masses can be cancerous.
• Infections such as mastitis and cellulitis tend to be erythematous, tender,
and warm to the touch. They may be more circumscribed if an abscess
formed.
• Similar symptoms may occur in patients with inflammatory breast cancer.
Therefore, caution should be used in assessing patients with suspected
breast infections.
11. APPROACH TO BREAST LUMP
• After the clinical breast examination is performed, the evaluation
depends largely on the patient’s age and examination characteristics,
and the physician’s experience in performing fine-needle aspiration.
• Fibroadenoma is the most common benign breast mass; invasive ductal
carcinoma is the most common malignancy.
• Trauma to the breast may result in a breast mass due to the
development of fat necrosis or a hematoma. Any mass after a trauma
that fails to resolve will require a complete evaluation.
12. Key clinical recommendation Label
Ultrasonography-guided CNB to diagnose malignancy in women with palpable breast
lesions.
C
In young women with dense breast tissue, ultrasonography should be used to detect
breast lesions.
C
Mammography should be used to detect in situ carcinomas of the breast. C
Diagnostic mammography is indicated in women older than 40 years if FNA reveals a
solid mass.
C
Excisional biopsy should be performed in women with clinically suspicious lesions, or
lesions that are equivocal on imaging, FNA, or CNB.
C
Cystic lesions that resolve after FNA do not require further evaluation unless they recur. C
If CBE, FNA, and imaging indicate benign disease, the CBE should be repeated in four
six weeks.
C
CNB = core-needle biopsy; FNA = fine-needle aspiration; CBE = clinical breast examination.
13. TRIPLE TEST
• The triple test is the combination of results from CBE, imaging, and tissue sampling.
• When the three assessments are performed adequately and produce concordant
results, the triple test diagnostic accuracy approaches 100 percent.
• A three-point scale is used to score each component of the triple test (1 = benign, 2 =
suspicious, 3 = malignant).
• A TTS of 3 or 4 is consistent with a benign lesion; a TTS of 6 or more indicates
possible malignancy that may require surgical intervention.
• Excisional biopsy is recommended in patients with a TTS of 5 to obtain a definitive
diagnosis.
14.
15. BI-RADS CLASSIFICATION
• Normal mammography does not exclude the presence of cancer because it misses
about 10 to 15 percent of clinically palpable breast cancers.
• BI-RADS classification developed to describe mammography results.
• In general, most palpable masses are considered suspicious for malignancy and are
assessed as BI-RADS 4 or higher.
• A palpable breast mass that is not visualized on mammography warrants further
workup.
• Routine follow-up is acceptable in patients with benign findings.
• Suspicious abnormalities should be biopsied.
18. INTRODUCTION
• Evaluation of breast pain (mastalgia) is important to determine whether the pain is due
to normal physiological changes related to hormonal fluctuation or to a pathologic
process such as breast cancer.
• Breast pain is usually mild, affect approximately 11 percent women.
• Breast pain may be cyclical (two-thirds) or noncyclical (one-third).
19. CYCLICAL PAIN
• Cyclical pain associated with hormonal changes of the menstrual cycle, usually
presenting in the week prior to onset of menses, bilateral, and most severe in the
upper outer quadrant of the breasts.
• For many women, cyclical breast pain can cause problems with their activities of daily
living. This interfered with:
●Sexual activity
●Physical activity
●Social activity
●School activity
20. NONCYCLICAL PAIN
• Noncyclical pain is more likely related to a breast or chest wall lesion and may be
constant or intermittent. Solitary cysts, when the presentation is abrupt, are frequently
painful.
• Noncyclical breast pain does not follow the usual menstrual pattern and is more likely
to be unilateral and variable in its location in the breast. Multiple etiologies can cause
noncyclical breast pain.
21. CONT…
Noncyclical breast pain:
• Large pendulous breasts: cause pain due to stretching of Cooper's ligaments. Neck,
back, and shoulder pain, rash and headache may be present.
• Diet and lifestyle:
Nicotine may increase breast pain.
• Hormone replacement therapy.
• Ductal ectasia characterized by distention of subareolar ducts due to inflammation
unrelated to infection associated with fever and acute local pain and tenderness
caused by penetration of the duct wall by lipid material, which may resolve to leave a
subareolar nodule.
22. CONT…
• Mastitis or breast abscess: most common in lactating women in the first month after
giving birth, but can also occur in women not lactating. It is usually caused by an
obstructive lactopathy
When initiating lactation, the nipple and areolar skin often undergo local inflammation
and swelling. This swelling results in relative obstruction to milk flow that can then be
seeded by skin bacteria (Staphylococcus aureus or Streptococcal species) leading to
bacterial mastitis. The breast becomes diffusely painful, swollen, and red; with an area of
fluctuance and eventually pointing if an abscess develops.
23. CONT…
• Inflammatory breast cancer: present with pain and a rapidly progressing tender, firm,
enlarged breast. The skin over the breast is warm and thickened, with a "peau
d'orange" (orange skin) appearance, but there is often no fever or leukocytosis.
• Hidradenitis suppurativa: can involve the breast and present as breast nodules and
pain.
• Other: pregnancy, thrombophlebitis, trauma, macrocysts, prior breast surgery, and a
variety of medications (hormones as well as some antidepressants, cardiovascular
agents, and antibiotics).
24. EXTRAMAMMARY PAIN
Extramammary pain may be from musculoskeletal sources such as chest wall pain, spinal or
paraspinal problem, trauma or scarring from prior biopsy.
• It may also be related to medical problems such as biliary, pulmonary, esophageal, or
cardiac disease.
• Chest wall pain: is frequently due to the pectoralis major muscle, related to actions that
strain or use the pectoral muscle repetitively. The pain can be reproduced by asking the
patient to place her hand flat on the iliac wing and push inward.
usually presenting bilateral, parasternal discomfort, can arise from costochondritis (typically
the second through fifth costochondral junctions) or Tietze's syndrome (typically second
and third costochondral junctions).
Local heat, analgesics and reassurance are the management.
25. CONT…
• Spinal and paraspinal disorders: occurs in older women in whom vertebral, spinal, and
paraspinal problems in the neck and upper thorax accumulate with age.
• Other – Chest wall pain induced by trauma or trauma-induced fat necrosis, intercostal
neuralgia often due to a respiratory infection, and underlying pleuritic lesions can mimic
benign breast disease. Gallbladder disease or ischemic heart disease may present as
intermittent chest pain.
Postthoracotomy syndrome is an unusual disorder in which a healing chest wound
simulates the effect of a suckling infant. It can be associated with an elevated prolactin
concentration, breast pain, and milk production. A similar effect can be seen with other
forms of chest wall irritation, including burns and chafing from clothing overlying the
nipple.
26. ASSOCIATION WITH BREAST CANCER
• Mastalgia has not been shown to be a risk factor for breast cancer.
• The presence of an associated breast cancer in a patient who presents with only pain is
extremely low, ranging from 0.5 to 3.3 percent.
• The pain is typically associated with adjacent benign, cystic breast tissue rather than
the cancer.
• Pain may also occur following a core biopsy of the cancer rather than being associated
with the cancer itself.
28. HISTORY
-Pain site -Concurrent neck, back, or shoulder problem
-Unilateral or bilateral -Fever
-Pain character -Local erythema
-Pain severity -Phasic or not
-Drug history specially OCP
-Beginning of the pain after a recent birth or pregnancy loss or termination
-Related to vigorous or repetitive use of the pectoral muscle group
-Recent trauma to the chest, affecting her daily activity
29. PHYSICAL EXAMINATION
• The four breast quadrants, subareolar areas, axillae, supraclavicular and infraclavicular areas
should be examined with the woman both lying and sitting with her hands on her hips and
then above her head.
• Check for skin changes noting the symmetry and contour of the breasts, position of the
nipples, scars, skin retraction, dimpling, edema or erythema, ulceration or crusting of the
nipple, and changes in skin color
• Check for enlarged axillary, supraclavicular, or infraclavicular lymph nodes
• Delineate and document breast masses
• Check for nipple discharge
• Identify localized areas of tenderness and relate them to areas of pain noted by the woman
and to other physical findings
30. EVALUATION
• For most women who present with breast pain, If the pain is diffuse and symptoms
classic for cyclical breast pain, neither a mammogram nor ultrasound are needed.
• In that clinical setting, a targeted ultrasound is the optimal study for women under age
30 with no high risk factors for breast cancer (eg, family history of premenopausal
breast cancer).
• For women over age 30, a mammogram and a targeted ultrasound can be performed.
• For women with focal pain without a mass, a targeted ultrasound or a mammogram
should be performed.
31. CONT…
• In the clinical setting of a suspicious finding, a mammogram is performed for women
of any age.
• Positive imaging studies require appropriate follow-up.
32. TREATMENT
• Role of diet and lifestyle:
A low fat, high complex carbohydrate diet has been effective in some observational
studies.
Elimination of caffeine has not been effective in controlled trials, although it seems to be
helpful in some women.
• Symptomatic relief:
Support garments: A well-fitting brassiere to better support breast.
The use of support bra with steel underwire tends to reduce mastalgia in women with
pendulous breasts.
Use of a "sports bra" during exercise has been shown to reduce pain related to breast
movement.
Compresses: Some women obtain relief from application of warm compresses or ice
or gentle massage.
33. CONT…
• Medical therapy:
Acetaminophen or NSAID, or both can be used to relieve breast pain. Topical NSAIDs
may also be useful.
Postmenopausal hormone therapy can cause breast pain and should be decreased
discontinued.
Oral contraceptives can reduce breast pain severity and duration in some women
cyclical symptoms.
Progestogens also improve breast pain symptoms in some women.
34. CONT…
Danazol is the only medication approved by the US FDA for the treatment of mastalgia.
It is effective at relieving breast pain and tenderness but it causes significant
androgenic effects.
For patients with more severe mastalgia, tamoxifen 10 mg can provide breast pain
relief. Tamoxifen also increases the risk of blood clots, strokes, uterine cancer, and
cataracts. Tamoxifen is infrequently used for this indication.
35. Clinical recommendation Evidence rating
Ultrasonography should be performed
in all patients with focal breast pain,
with adjunctive mammography in
patients 30 years and older.
C
Danazol can be used to treat mastalgia.
Dosing only during the luteal phase
may reduce androgenic effects.
A
38. NIPPLE DISCHARGE
• Nipple discharge is the one of the most commonly encountered breast complaints.
• Most nipple discharge is benign origin.
• The clinical history is most helpful in distinguishing benign from suspicious or
pathologic nipple discharge.
• Benign nipple discharge is usually bilateral, multiductal, and occurs with breast
manipulation.
• Conversely, the risk of cancer is higher when the discharge is spontaneous, bloody,
unilateral, uniductal, associated with a breast mass, and/or occurs in a woman over 40
years of age.
39. HISTORY
• If discharge is spontaneous or provoked by manipulation of the breast
• History of recent trauma
• Color of the discharge
• Associating with a mass
• Unilateral or bilateral
40. PHYSICAL EXAMINATION
• the skin covering the breast and nipple areolar complex should be examined for
lesions.
• Gentle, firm pressure should be applied at the base of the areola (not on the nipple),
massage from the periphery towards the nipple areolar complex may also help to
detect nipple discharge.
41. PHYSIOLOGIC DISCHARGE
• Bilateral milky nipple discharge is appropriate during pregnancy and lactation, and
may persist for up to one year postpartum or after cessation of breastfeeding.
• Usually bilateral, involves multiple ducts, and is associated with nipple stimulation or
breast compression.
• Bilateral nonpathologic milky white discharge in persons who are not pregnant or
lactating is called galactorrhea; a human chorionic gonadotropin pregnancy test
should be performed in patients with galactorrhea to rule out pregnancy.
• If negative, prolactin and thyroid-stimulating hormone levels should be obtained to
determine the presence of an endocrinopathy.
42. CONT…
• Stresses such as trauma, surgical procedures, and anesthesia may also inhibit
dopamine release, thereby causing hyperprolactinemia and inducing galactorrhea.
• Purulent nipple discharge can be seen in association with periductal mastitis.
• Neurogenic stimulation represses the secretion of hypothalamic prolactin inhibitory
factor, resulting in hyperprolactinemia and galactorrhea.
• Decreases in nipple stimulation and breast compression expedite the resolution of
physiologic discharge.
43. CONT…
• Postthoracotomy syndrome is an unusual disorder in which the healing chest wound
simulates the effect of a suckling infant. It can be associated with an elevated prolactin
concentration, breast pain, and milk production. It can be seen with other forms of
chest wall injury, including burns, cervical spine lesions, and herpes zoster.
• There are some medications that inhibit dopamine and are associated with physiologic
nipple discharge
44.
45. PATHOLOGIC DISCHARGE
• Secretory production of fluids other than milk may be due to a pathological process in
the breast.
• It is spontaneous, unilateral, localized to a single duct and persistent
• The most common cause is intraductal papilloma.
• The discharge associated with a papilloma can be clear or grossly bloody.
• Mammography and subareolar ultrasonography should be performed in patients with
nipple discharge that is unilateral, spontaneous, clear, serous, bloody, or associated
with a mass.
46. CONT…
• Those with pathologic discharge, even with normal imaging findings, should be
referred to a surgeon for duct excision.
• Cytology of the nipple discharge is not recommended, because the absence of
malignant cells does not exclude cancer.
47. DIFFERENTIAL DIAGNOSIS
• The color of nipple discharge can provide an indicator of the risk of underlying
malignancy.
48. STRAW-COLORED OR CLEAR
TRANSPARENT DISCHARGE
• It is typically due to a papilloma but may be associated with a malignancy.
• This discharge is typically a straw-colored, transparent, sticky fluid.
• It is very much like plasma.
• Unilateral spontaneous serous discharge is considered suspicious and requires a full
workup.
49. BLOODY DISCHARGE
• Grossly bloody nipple discharge simply means that a lesion in the duct is bleeding.
• The bleeding can be caused by an intraductal carcinoma (in-situ or invasive), a
bleeding papilloma, or benign fibrocystic changes with an active intraductal
component (eg, plasma cell mastitis, ductal ectasia, intraductal hyperplasia, or
papillomatosis).
• The cause of bloody nipple discharge in women during pregnancy and lactation is
usually hypervascularity of developing breast tissue, which is benign and requires no
treatment.
50. STAINING OF THE BRA WITHOUT
OBVIOUS NIPPLE DISCHARGE
• A woman may report finding a stain or spot of blood on her brassiere or underclothing
which merits careful examination of the skin around the nipple and nipple-areolar
complex.
• While skin changes such as dermatitis or eczema and associated excoriations can
occur, it is important to rule out Paget disease with a skin biopsy if the lesions persist
after conservative treatment.
• Paget disease is a breast cancer, characterized clinically by an eczematoid appearance
with nipple crusting, scaling, or erosion.
55. • A 15-year-old adolescent boy comes to your office complaining of bilateral breast
enlargement. He is otherwise healthy and on no medications. On examination, there is
mildly tender palpable breast tissue bilaterally. The rest of his physical examination,
including his testicular examination, is normal. Which of the following is true?
a. No further workup is necessary.
b. Serum liver studies will help to elucidate the cause.
c. Thyroid function assessment will help to elucidate the cause.
d. Serum estradiol, testosterone, and leutinizing hormone levels are needed to elucidate
the cause.
e. His serum chorionic gonadotropin level is likely to be elevated.
56. The answer is a.
Gynecomastia is a benign enlargement of the male breast. It may be asymptomatic or
painful, bilateral, or unilateral. It commonly occurs around the time of puberty, and if
requires only a history, physical, examination, and reassurance if there are no
abnormalities found. Most cases resolve within 1 year. Outside the pubertal period,
assessment of hepatic, renal, and thyroid functions may help uncover a cause. Sex
hormones are only tested if progressive enlargement is noted.
57. A 14-year-old boy presents with tenderness associated with the right breast. There are
no other findings. Testicular examination is unremarkable. Appropriate management of
this patient includes
A) Mammogram
B) Ultrasound of the breast
C) Genetic typing
D) Biopsy
E) Reassurance and continued observation
58. The answer is E.
Benign gynecomastia of adolescence is a very common finding among boys in middle
late puberty. The breast tissue is usually asymmetric and often tender to palpation.
Provided the history and physical examination, including palpation of the testicles, are
unremarkable, reassurance and periodic reevaluation are all that is necessary. Most
resolve in 1 to 2 years. Familial gynecomastia is a common genetic disorder transmitted
as a X-linked recessive trait or a sex-limited dominant trait causing limited breast
development around the time of puberty. It requires no further evaluation in an
otherwise normal boy unless there is evidence of hypogonadism. In rare cases, those
severe gynecomastia may require cosmetic surgery. Pathologic gynecomastia occurs in
cases of Klinefelter’s syndrome and prolactin-secreting adenomas and with a wide
of drug use including marijuana and phenothiazines.
59. • A 22-year-old woman is seeing her physician with complaints of breast pain. It is
associated with her menstrual cycle and is described as a bilateral “heaviness” that radiates
to the axillae and arms. Examination reveals groups of small breast nodules in the upper
outer quadrants of each breast. They are freely mobile and slightly tender. Which of the
following statements is most accurate?
a. The patient has bilateral fibroadenomas, and reassurance is all that is necessary.
b. The patient has bilateral fibroadenomas, and a mammogram is necessary for further
evaluation.
c. The patient has bilateral fibrocystic changes, and reassurance is all that is necessary.
d. The patient has bilateral fibrocystic changes, and a mammogram is necessary for further
evaluation.
e. The patient has bilateral mastitis and antibiotic therapy is needed.
60. The answer is c.
Fibrocystic changes are the most common benign condition of the breast. Cysts may
range in size from 1 mm to more than 1 cm in size. Fibroadenomas are usually rubbery,
smooth, well-circumscribed, nontender, and freely mobile. Mammograms are not
necessary for women younger than 30 years of age, as they are less sensitive in
women with denser breast tissue. Mastitis generally occurs with nursing, and is
characterized by inflammation, edema, and erythema in areas of the breast.
61. • A 35-year-old woman presents to you concerned about a breast mass. Examination
reveals no skin changes, diffusely nodular breasts bilaterally with a more dominant, firm,
and nontender fixed nodule on the left side. The nodule is approximately 7 mm in size,
in the upper outer quadrant of the left breast. Her mammogram is negative. Which of
the following statements is true?
a. The patient should be reassured and resume routine care.
b. The mass should be closely followed with repeat mammogram in 3 to 6 months.
c. The patient should undergo testing for breast cancer genetic mutations, and base
further workup on the results.
d. The patient should be referred for an ultrasound and possible biopsy.
e. If clear amber fluid is aspirated from the mass, it is likely benign, and no further workup
is necessary.
62. The answer is d.
Up to 15% of breast cancers are mammographically silent. Therefore, a palpable mass
deserves further workup, even if the mammogram is negative. Workup may include an
ultrasound to determine if the mass is cystic or solid, and possible biopsy. Aspiration of
the mass may be appropriate, but biopsy is still necessary if the mass is palpable after
aspiration, if the fluid is bloody, or if the mass reappears within 1 month. The
characteristics of the fluid otherwise do not dictate workup. Genetic testing is of no
in the workup of a breast mass, but can be considered based on family history, and
under the direction of an experienced genetic counselor.
63. • A 28-year-old woman comes to see you for a tender and erythematous area on her
breast. She is nursing her 6-week-old son. You diagnose mastitis. Which of the
following is true regarding this condition?
a. Restricting caffeine and methylxanthine may be efficacious.
b. Evening primrose oil has been shown to help with symptoms.
c. Applying ice several times a day will help relieve symptoms.
d. The patient should discontinue nursing.
e. Antibiotic therapy is indicated.
64. The answer is e.
Patients with mastitis should be encouraged to continue nursing, and should be started
on an antibiotic that covers streptococcal and staphylococcal infections. Reducing
caffeine and methylxanthines, or using evening primrose oil may decrease symptoms of
fibrocystic breast disease, but has no impact on mastitis. Applying heat may help
symptoms, but ice will not have the desired effect.
65. • You are seeing a 36-year-old woman with a complaint of nipple discharge. Which of
the following characteristics of the discharge is most suspicious for breast cancer?
a. Spontaneous discharge
b. Green discharge
c. Bilateral discharge
d. Discharge associated with menses
e. Bloody discharge
66. The answer is a.
Spontaneous, unilateral discharge is most suspicious for breast cancer. The
characteristics of the discharge cannot be used to distinguish benign versus malignant
causes; however, bloody, serous, serosanguineous, or watery discharge deserves a
workup.