Family medicine
Breast Pain (mastalgia)
Mastalgia is breast pain that may be cyclical (related to hormonal fluctuations of the menstrual cycle) or noncyclical (arising from musculoskeletal, inflammatory, or other local causes), and is usually benign.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Cyclical mastalgia (fibrocystic changes) [3][4] | Bilateral diffuse pain, worse premenstrually, resolves with menses; no discrete mass; reproductive age | 「痛係咪嚟M之前嚴重啲，嚟完就好返？」 |
| Non-cyclical mastalgia (idiopathic / musculoskeletal) | No relation to cycle; may be focal; reproduced by pressing chest wall | 「撳呢度會唔會翻痛？同M有冇關係？」 | |
| Serious Not To Miss | Breast carcinoma (~5% present with pain) [1][5] | Progressive hard lump, skin dimpling/peau d'orange, bloody nipple discharge, axillary lymphadenopathy | 「有冇摸到硬嘢越嚟越大？皮膚有冇凹咗？乳頭有冇出血？」 |
| Inflammatory breast cancer | Rapid onset, erythema, peau d'orange, warm swollen breast, may mimic mastitis | 「成個胸有冇紅晒、脹晒、好似發炎噉但係好快？」(Exam: diffuse erythema + peau d'orange, no response to antibiotics) | |
| Breast abscess | Fever, focal fluctuant swelling, erythema; may be lactational or non-lactational | 「有冇發燒？個位有冇紅腫、按落去軟身有膿嘅感覺？」 | |
| Pitfalls | Costochondritis / Tietze syndrome | Chest wall tenderness reproduced on palpation of costochondral junction; not true breast pain | 「你撳胸骨旁邊嗰度會唔會痛？」(Exam: tenderness at costochondral junction) |
| Duct ectasia | Periareolar pain, non-cyclical; green/creamy nipple discharge; older women | 「乳頭有冇出綠色或者乳白色嘅嘢？」 | |
| Fat necrosis | History of trauma or surgery; firm, painless or mildly tender lump; can mimic cancer on imaging | 「之前胸部有冇撞親或者做過手術？」 | |
| Masquerades | Drug-induced mastalgia | Temporal relation to starting COC, HRT, SSRIs, spironolactone, digoxin | 「最近有冇開始食新藥？」 |
| Pregnancy | Amenorrhoea, bilateral breast tenderness and engorgement | 「M有冇遲咗？有冇可能懷孕？」 | |
| Trying to Tell Me Something? | Cancer anxiety / psychosocial stress | Disproportionate worry; recent relative/friend diagnosed with breast CA; anxiety affecting function | 「你最擔心係咩？屋企或者身邊有冇人最近確診乳癌？」 |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, introduce self, set agenda | 「你好呀，我係X醫生，今日由我負責同你傾。你今日嚟有咩唔舒服呀？」 | Rapport, interpersonal marks; open question invites patient's own words |
| 0:30–1:30 | Chief complaint & HPI — SOCRATES for breast pain, cyclical vs non-cyclical, uni/bilateral, associated lump/discharge/skin changes | 「你個胸痛咗幾耐呀？係邊邊痛？一邊定兩邊？」「痛係點樣痛法？有冇同經期有關？嚟M之前痛啲，嚟完好返？」「有冇摸到有粒嘢？有冇乳頭出水？皮膚有冇變化？」 | Establishes cyclical vs non-cyclical; screens for associated mass/nipple discharge (red flags) |
| 1:30–2:30 | Red flags & cancer screening — progressive lump, skin dimpling/peau d'orange, bloody nipple discharge, axillary lump, weight loss, bone pain, SOB; FHx breast/ovarian CA | 「有冇發覺粒嘢越嚟越大？皮膚有冇凹咗落去？乳頭有冇出血？腋下有冇脹咗？近排有冇瘦咗？骨有冇痛？」「你屋企人有冇人生過乳癌或者卵巢癌？」 | Detects serious disorders not to miss — progressive breast lump enlargement is suggestive of malignancy [1] |
| 2:30–3:30 | Menstrual/Obs/Gyn Hx, Drug Hx, Risk factors — menarche, menopause status, parity, breastfeeding, COC/HRT, previous breast disease, chest wall trauma | 「你幾歲開始嚟M？M有冇停咗？你有冇仔女？餵過人奶未？食緊避孕丸或者荷爾蒙藥？」 | Estrogen exposure affects risk; drugs (COC/HRT) cause mastalgia; Hx of breast RT/DCIS is high risk [2] |
| 3:30–4:30 | ICE — uncover hidden agenda | 「你自己覺得痛嘅原因可能係咩呀？」(Ideas) 「你最擔心啲咩？」(Concerns) 「你今日嚟最想我幫到你啲咩？」(Expectations) 「點解你揀今日嚟睇呢？」(Hidden agenda — e.g. relative just diagnosed with breast CA?) | Direct ICE marks; "Why today?" often reveals the hidden concern (e.g. cancer worry, a relative/friend recently diagnosed) |
| 4:30–5:15 | Summarise, signpost, suggest plan | 「等我總結一下：你胸痛咗X個月，每次嚟M之前嚴重啲，冇摸到硬嘢，冇出血，屋企人冇乳癌。你最擔心係唔係癌症。我聽到嘅啱唔啱？」 | Summarising scores interpersonal marks; shows active listening |
| 5:15–6:00 | Explain likely Dx, safety net, close | 「根據你講嘅情況，最大機會係良性嘅乳房纖維囊性變化引起嘅週期性痛。不過為咗安全，我會幫你安排檢查排除其他問題。如果你之後發覺有硬嘢、乳頭出血、皮膚凹陷，就要即刻返嚟。你有冇嘢想問？」 | Shows reassurance + safety net; closes respectfully |
Hidden agenda tip: A young woman presenting with breast pain often has an underlying fear of breast cancer — frequently triggered by a family member or friend's recent diagnosis. Ask 「點解你揀今日嚟睇呢？」 and 「有冇咩嘢令你特別擔心？」 to surface this.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Pain character | Is it related to your period? Worse before period, better after? | 「痛同經期有冇關係？嚟M之前痛啲，嚟完好返？」 | Cyclical vs non-cyclical mastalgia — cyclical = likely benign fibrocystic changes [3][4] | Cyclical → fibrocystic changes; Non-cyclical → duct ectasia, costochondritis, fat necrosis, cancer |
| Pain site | One side or both sides? | 「一邊定兩邊？邊個位最痛？」 | Bilateral diffuse → hormonal/fibrocystic; focal unilateral → cyst, abscess, or CA | Unilateral focal → needs imaging |
| Lump | Have you felt a lump? | 「你有冇摸到有粒嘢？」 | ~5% of breast cancers present with pain; must exclude coexisting mass [5] | Lump + pain → breast cyst (acute enlargement), abscess, or cancer |
| Nipple discharge | Any fluid from the nipple? What colour? | 「乳頭有冇出水？咩顏色？有冇血？」 | Bloody → intraductal papilloma or CA; creamy/green → duct ectasia [2] | Bloody discharge → urgent referral |
| Skin changes | Any dimpling, redness, or orange-peel changes? | 「皮膚有冇凹咗、紅咗、或者好似橙皮噉？」 | Peau d'orange is associated with inflammatory breast cancer [1] | Skin dimpling/peau d'orange → cancer |
| Axillary lump | Any swelling under your arm? | 「腋下有冇脹咗或者摸到嘢？」 | Axillary lymphadenopathy → metastatic CA | Firm, fixed nodes → urgent referral |
| Constitutional | Weight loss, bone pain, shortness of breath? | 「近排有冇瘦咗？骨有冇痛？有冇氣促？」 | Metastatic disease (bone, lung) [2] | Bone pain/SOB + breast symptoms → metastatic CA |
| Menstrual Hx | Age at first period? Regular? LMP? Menopause? | 「幾歲開始嚟M？幾時嚟最後一次？M停咗未？」 | Cyclical mastalgia by definition relates to menstrual cycle; postmenopausal mastalgia needs more concern | Postmenopausal new mastalgia → lower threshold for imaging |
| Obs/Gyn Hx | Children? Breastfed? | 「你有冇仔女？餵過人奶未？」 | Parity/breastfeeding affect estrogen exposure; lactation-related causes (mastitis, abscess) | Breastfeeding + pain + fever → lactational mastitis/abscess |
| Drug Hx | COC? HRT? Any medications? | 「食緊避孕丸？荷爾蒙藥？其他藥？」 | COC/HRT are common iatrogenic causes of mastalgia [2] | Drug-induced mastalgia (also SSRIs, spironolactone) |
| FHx | Any family history of breast, ovarian, prostate, or pancreatic cancer? | 「屋企人有冇人生過乳癌、卵巢癌、前列腺癌或者胰臟癌？」 | BRCA-related cancers [2] | Multiple affected relatives → genetic referral |
| PMHx | Previous breast problems? Biopsy? Radiation? | 「之前有冇試過乳房有問題？做過活檢或者電療？」 | Previous DCIS/breast RT increases CA risk [2] | Previous breast disease → higher suspicion |
| Chest wall | Does pressing on the rib/breastbone reproduce the pain? | 「你撳胸骨或者肋骨會唔會痛？」 | Distinguishes extramammary (costochondritis/Tietze's) from true mastalgia [5] | Reproducible chest wall tenderness → costochondritis |
| Psychosocial | Any stress? How is this affecting your daily life/work/sleep? | 「最近壓力大唔大？痛有冇影響你瞓覺、返工？」 | Stress/anxiety amplifies pain perception; functional impact = social problem for CRF | Anxiety/cancer phobia → psychological problem |
| Health-seeking | Why did you come today specifically? | 「點解你揀今日嚟？有冇咩事發生令你特別擔心？」 | Uncovers hidden agenda | Friend/relative diagnosed → cancer anxiety |
Case Report Form Answer Builder
- CC: Breast pain (mastalgia) × duration
- HPI high-yield points to capture:
- Onset, duration, progression
- Cyclical (related to menses) vs non-cyclical
- Unilateral vs bilateral; diffuse vs focal
- Associated lump, nipple discharge, skin changes
- Red flags screened and negative (or positive)
- Menstrual history, parity, breastfeeding, COC/HRT use
- Family history of breast/ovarian cancer
- Functional impact (sleep, work, mood)
- Likely examples:
- "To find out the cause of her breast pain"
- "Worried about breast cancer" (if ICE reveals this)
- "Breast pain affecting sleep/daily life"
- Best phrasing: Choose the one that aligns with the patient's stated concern, e.g. "Patient is concerned that her breast pain may indicate breast cancer."
| Example Wording | |
|---|---|
| Ideas | "Patient thinks the pain may be due to breast cancer / hormonal changes / a lump inside" |
| Concerns | "Patient is worried she may have breast cancer, especially because her aunt/friend was recently diagnosed" |
| Expectations | "Patient wants reassurance and/or an investigation (e.g. ultrasound or mammogram) to rule out cancer" |
| DDx | One Key Discriminator |
|---|---|
| 1. Non-cyclical mastalgia (idiopathic / musculoskeletal) | Pain unrelated to menstrual cycle; may be reproduced by chest wall palpation |
| 2. Breast cyst (with acute enlargement) | Sudden-onset focal pain; discrete smooth mobile lump on exam; confirmed on USG as anechoic lesion [6] |
| 3. Breast carcinoma | Progressive lump enlargement is suggestive of malignancy [1]; hard irregular lump, skin tethering, bloody discharge, axillary lymphadenopathy |
| Domain | Problem |
|---|---|
| Biological | Cyclical breast pain requiring exclusion of breast malignancy |
| Psychological | Anxiety about breast cancer (± triggered by family/friend diagnosis) |
| Social/Functional | Pain affecting sleep, work performance, or daily activities |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Cyclical mastalgia / fibrocystic changes (most likely) | Bilateral diffuse nodularity ("cobblestone" texture), tender on palpation, no discrete mass | Palpate all four quadrants systematically with flat of fingers at 45°; compare both breasts; examine premenstrually for maximal findings [4] | Diffuse nodularity without a discrete mass, with tenderness, is the hallmark of fibrocystic changes |
| Breast cyst | Discrete, smooth, mobile, firm lump; tender | Palpate; attempt to transilluminate (limited); confirm by USG | Well-defined, mobile, smooth lump suggests cyst (USG confirms anechoic lesion) [6] |
| Breast carcinoma | Hard, irregular, fixed/tethered mass ± skin dimpling ± peau d'orange | Palpate for hard lump; pinch skin overlying lump (dimpling); press hands on hips to test pectoralis fixation [2] | Spiculated mass, irregular border, fixation to skin/muscle, peau d'orange are signs of malignancy |
| Costochondritis | Tenderness at costochondral junction reproducible on palpation | Press on costochondral junctions (2nd–5th ribs); pain reproduced = extramammary cause | Localised chest wall tenderness reproducing patient's pain confirms musculoskeletal origin, not breast pathology |
| Breast abscess | Fluctuant, erythematous, warm, tender swelling ± fever | Inspect for erythema; palpate for fluctuance and warmth; check temperature | Fluctuance + erythema + fever = abscess (needs drainage) |
Must-Not-Miss Red Flags for Urgent Referral
- Progressive breast lump enlargement [1]
- Hard, irregular, fixed mass
- Skin dimpling / peau d'orange (associated with inflammatory breast cancer) [1]
- Bloody or spontaneous unilateral nipple discharge
- Nipple retraction/destruction/dermatitis (Paget's disease)
- Axillary lymphadenopathy (hard, fixed)
- Constitutional symptoms (weight loss, bone pain, SOB) suggesting metastases
- Postmenopausal new breast pain → lower threshold for investigation
Any of these → urgent triple assessment (clinical + radiological + histopathological) [2]
Top traps that lose marks:
- Forgetting to ask about a lump — mastalgia and mass are separate complaints but coexist; ~5% of breast cancers present with pain [5]
- Not distinguishing cyclical vs non-cyclical — this is the most important clinical discriminator and determines diagnosis
- Missing extramammary causes — costochondritis is a common pitfall; always press the chest wall
- Not exploring ICE — the hidden agenda is almost always cancer anxiety; failure to ask loses ICE marks AND interpersonal marks
- Forgetting drug history — COC, HRT, SSRIs, spironolactone cause mastalgia
- Mammogram in young women — for women < 35y, USG is the imaging of choice (dense breasts → mammogram insensitive, especially in Asians) [2][7]
- Writing "breast cancer" as most likely Dx when no red flags — cyclical mastalgia with no mass is overwhelmingly benign; write fibrocystic changes
- Not asking menstrual/obstetric history — this is essential to characterise cyclical mastalgia and assess estrogen exposure
Shortest safe management / safety-net line:
- Reassurance + well-fitting supportive bra + simple analgesics (paracetamol/NSAIDs)
- If persistent or severe: consider evening primrose oil; 2nd line: tamoxifen/danazol [4]
- Safety net: 「如果你之後發覺有硬嘢、乳頭出血、皮膚凹陷，就要即刻返嚟睇。」
High Yield Summary
What to ASK:
- Cyclical vs non-cyclical? Uni- vs bilateral? Associated lump/discharge/skin changes?
- Red flags: progressive lump, skin dimpling/peau d'orange, bloody nipple discharge, axillary mass
- Menstrual/Obs/Drug Hx (COC/HRT); Family Hx (BRCA cancers)
- Chest wall tenderness (costochondritis pitfall)
- ICE + "Why today?" → hidden agenda is almost always cancer anxiety
What to WRITE on the CRF:
- Most likely Dx: Cyclical mastalgia / fibrocystic breast changes
- DDx: Non-cyclical mastalgia, breast cyst, breast carcinoma
- Biopsychosocial: (B) Cyclical mastalgia needing exclusion of CA; (P) Cancer anxiety; (S) Impact on sleep/work
- Physical sign: Bilateral diffuse breast nodularity and tenderness, no discrete mass
What NOT to MISS:
- ~5% of breast cancers present with pain — always screen for coexisting mass
- Peau d'orange = inflammatory breast cancer until proven otherwise
- Young woman ( < 35y) → USG first, not mammogram
- Progressive lump enlargement is the sinister symptom on past papers [1]
Active Recall - Family Medicine Clinical Test
[1] Past papers: 2025 Fourth Summative MCQ (Q21 — peau d'orange associated with inflammatory breast cancer; Q23 — progressive breast lump enlargement suggestive of malignancy) [2] Senior notes: Maksim Surgery Notes.pdf (p179 — triple assessment, history taking for breast, risk factors including BRCA/estrogen exposure) [3] GC lecture slides: GC 181. Breast mass breast cancer; benign breast diseases; mammography; breast cancer screening.pdf (p10 — clinical history for breast symptoms: lump, pain, nipple discharge, duration, changes, unilateral/bilateral) [4] Senior notes: Ryan Ho Urogenital.pdf (p202 — cyclical mastalgia management, fibrocystic changes presentation) [5] Lecture slides: Breast Examination_A Kwong_updated 1_9_2023_short upload version.pdf (p7 — less than 5% of cancer presented with pain; cyclical vs non-cyclical; extramammary causes e.g. costochondritis) [6] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (p274 — breast cyst diagnosis: USG simple cyst = well-circumscribed anechoic lesion) [7] Senior notes: Ryan Ho Radiology.pdf (p29, p37, p40 — mammogram insensitive in young/Asian women with dense breasts; USG preferred for young patients)
Breast Lump
A palpable mass in the breast that may represent a benign condition such as a fibroadenoma or cyst, or a malignant neoplasm requiring further evaluation with imaging and possible biopsy.
Calf Pain
Calf pain is discomfort in the posterior lower leg that may arise from musculoskeletal strain, deep vein thrombosis, peripheral arterial disease, or neurogenic causes, requiring careful evaluation to exclude vascular emergencies.