CASE: ACUTE BREAST ISSUE (MALIGNANT BREAST MASS)
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.
TRIAGE QUESTIONS
What are the first steps in triaging Adele? What is necessary to assign an ESI? (N)
· Airway, Breathing, Circulation; objective assessment and targeted subjective questioning focusing on signs/symptoms of acuity/hemodynamic instability
o GEN – fever, chills?
o CV – lightheadedness, dizziness, palpitations?
o Resp – SOB?
o GYN – LMP?
· Vital signs
· Pain assessment – (O)PQRST model as an example
o Onset, provoke/palliate, quality, radiation, severity, timing
· Screening for violence, trauma
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
What ESI (Emergency Severity Index) level would you assign Adele and why? (N)
· ESI = 5, based on normal vital signs, no systemic findings and no ED resources likely needed
Is there any other information important to gather at triage? (N)
· Medication compliance – did she take her medications this morning?
· Focused past medical history – is she being treated for hypertension since BP is elevated?
What would you communicate to the primary nurse? How would you orient Adele to the next steps of care? (N)
· Communication to primary nurse – verbal is ideal, but may only use EDIS (electronic patient tracking system)
o Example “60 year old female, cc: left breast mass, ESI 5, waiting room”
· Communication to Adele
o Reassurance that she will be evaluated as soon as possible
o Compassionate, non-judgmental manner
PRIMARY NURSE ASSESSMENT
Once triaged, what nursing steps should occur before initial provider assessment (i.e. care, assessment)? (N)
· Nursing care
o Escort patient to a private room
o Have her undress from the waist up, gown that opens in the front, provide a blanket/sheet for comfort/modesty
o Orient to flow of ED, orient to exam room details (i.e. call bell)
o Reassure her that provider will be with her as soon as possible and that she can call nurse if needed
o Anticipate need for female chaperone
· Nursing assessment
o Additional HPI, ROS and OB/GYN history – including Gravida/Para?
o Family and social histories – personal or family history of cancer?
o Screening for violence/trauma/SI (if not done at triage)
o Medication reconciliation, allergy assessment
o Reassessment from triage findings
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
What would you communicate with the provider? (N)
· Notify provider of immediate needs
· Update provider on changes in condition since triage
· Summarize pertinent findings (SBAR approach is one example of systematic way to provide report)
· Example “Adele is a healthy 60yo female in room 2. She found a left breast lump this morning during her shower. She has never done a self-breast exam before. Her sister has ovarian cancer, and Adele is worried she might have breast cancer. She was slightly hypertensive in triage, but her blood pressure has improved. She is a bit anxious. Adele is in a gown, and I am available to chaperone your exam when you are ready.”
PROVIDER ASSESSMENT
What historical questions would you ask Adele during your assessment? (P)
· Targeted history & ROS (to complement what has already been asked/obtained) See question list below
· Medical and surgical histories
· OB/GYN history, including menstrual history
· Family history
· Social history
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?
What elements of the physical exam would you perform? What key findings are you looking for? (P)
· Physical exam with breast exam to specifically evaluate for
o Breast asymmetry
o Breast skin changes – tenting, discoloration, “orange peel” appearance, excoriations, ulcers, ecchymosis; signs of acute infection/cellulitis – redness, warmth, streaking
o Mass – location, size, consistency, mobility, tenderness, well-defined?
o Nipple discharge
o Axillary & supraclavicular lymph nodes
How do you prepare for the breast exam? How do you prepare Adele for the breast exam? (N&P)
· (N) Gather and set-up supplies and equipment
o Appropriate exam table and proper positioning of patient
· (N&P) Ensure appropriate female chaperone
· (NP) Attend to privacy
o Private room, pull curtain, sign on door/locked door
o Appropriate gowning and draping
· (P) Explanation of breast exam process, verbal consent
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
WORKING DIFFERENTIAL DIAGNOSIS AND EVALUATION
What is your differential diagnosis? What is your lead/working diagnosis and why? (P)
· Breast mass
o Malignant
o Non-malignant – fibroadenoma, cyst
Based on the working differential diagnosis of the provider, what would you anticipate being ordered? (N)
· Discharge from ED
· Telephone consult with surgeon on call
· Urgent follow-up with surgery and primary care
How would you summarize your findings and plan to Adele and nursing? (P)
· Key exam findings
· Concerns
· Next steps in care (recall your facility has limited after-hours radiology, including US)
· Example “Adele, I’m impressed by your self-awareness of your breast that helped you find the lump and for coming in to get it evaluated so quickly. I could feel the firm 2cm mass in the upper outer part of your left breast that you felt this morning. I can’t tell what it is just by feeling it, but I am concerned about things like a cyst, non-cancerous mass or even a cancerous mass. It definitely needs further evaluation with breast imaging, like a mammogram and possible biopsy. I’m going to touch base with our surgeon to get their opinion and I’ll be back to let you know what this plan is. I will also let your primary care provider know you were in the ED today and what we found. You can change back into your clothes now. Would you like to have your husband to join you now?”
MANAGEMENT
Do you order any blood work? (P)
· None indicated
What are your next steps in the ongoing management of Adele? (P)
· Telephone consult today to general surgeon, discuss case and determine appropriate follow-up
· Send priority message/additional signer to primary care provider with plan of care
· Radiology consult per surgeon’s recommendation, appointment, biopsy
· Communicate with WVPM/breast care coordinator to help facilitate follow-up (depending on your facility’s resources)
What information do you communicate to the consultant? (P)
· 60 yo female with no significant breast history now with new left breast lump
· Exam shows 2cm firm, fixed, slightly tender left upper outer quadrant; no lymph nodes appreciated
· Last mammogram was 5 yrs ago and was normal
· Planning to facilitate mammogram; requesting early General Surgery appointment and biopsy
· Making PCP/PACT team and WVPM/breast care coordinator aware to facilitate continuity of care
What are your next steps in the ongoing management of Adele? (N)
· Recheck vital signs
· Reassess anxiety level
· Provide follow-up information based on surgeon’s recommendation
· Provide information on how to contact PCP/PACT team, WVPM/breast care coordinator
· Prepare discharge to home
How would you orient/summarize Adele to the plan of care? (N)
· Discharge summary which include next steps in care, reassessment, comfort and compassion
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.
HANDOFF/DISPOSITION
What are the proper handoff procedures in this scenario? (P&N)
· Discharge to home
· Patient follow-up with General Surgery based on referral plan
· Patient follow-up with PCP and/or WVPM/breast care coordinator
· Patient education and support
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
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