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.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Fibroadenoma | Young woman (15–35), smooth, mobile, rubbery, non-tender – "breast mouse" | 「個硬塊會唔會郁嚟郁去？」(Does the lump move around?) – highly mobile | ~25% |
| Breast cyst | Smooth, well-defined, may be tender; sudden onset | 「係咪突然間出現？按落去有冇彈性？」(Sudden? Fluctuant?) – USG: anechoic with posterior enhancement [7] | ~25% | |
| Fibrocystic change | Bilateral, cyclical pain/lumpiness, pre-menopausal | 「嚟M之前會唔會特別脹痛？」(Worse before period?) | ~20% | |
| Serious Not To Miss | Breast carcinoma | Hard, irregular, fixed, painless, skin/nipple changes, axillary LN | 「個硬塊硬唔硬？郁唔郁到？」– Stony hard, immobile, peau d'orange [4][5] | ~10% |
| Phyllodes tumour | Rapidly enlarging, large, smooth; can be benign or malignant | 「個硬塊係咪好快大咗好多？」– Rapid growth in older woman | ~1% | |
| Inflammatory breast CA | Diffuse erythema, warmth, peau d'orange, rapid progression, ≥1/3 breast involved | 「個胸有冇又紅又腫又熱？」– T4d; mimics mastitis but no response to antibiotics [5] | < 1% | |
| Pitfalls | Breast abscess / mastitis | Acute, red, hot, tender, fluctuant; fever; often lactating | 「有冇發燒？個位紅唔紅、熱唔熱？」 | ~5% |
| Fat necrosis | History of trauma or surgery; firm, irregular – mimics cancer | 「之前有冇撞親個胸或者做過手術？」 | ~2% | |
| Intraductal papilloma | Bloody/serous unilateral nipple discharge; small subareolar lump | 「有冇一邊乳頭出血水？」 | ~2% | |
| Masquerades | Chest wall pathology (costochondritis, rib lesion) | Pain deep to breast, reproducible on palpation of rib/costal cartilage | 「痛嘅位置係皮膚面，定係入面骨嗰度？」 | ~5% |
| Drug-induced (HRT, OCP, antipsychotics) | Bilateral breast changes; medication history | 「你食緊咩藥？有冇荷爾蒙藥或者精神科藥？」 | ~2% | |
| Trying to Tell Me Something? | Cancer anxiety / family bereavement / body image | Recent family member diagnosed; fear of death; worry about partner | 「你最擔心係咩？有冇屋企人最近唔舒服？」 | ~30% |
6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好，我係X醫生，今日由我同你傾。你可唔可以話我知今日點樣嚟到嘅？有咩嘢我可以幫到你？」(Hello, I'm Dr X, how can I help you today?) | Examiner marks first impression, rapport, patient-centredness |
| 0:30–1:30 | Chief complaint + HPI – lump details, duration, change, associated symptoms | 「你幾時開始發現個硬塊？有冇越嚟越大？痛唔痛？有冇乳頭出水或者凹陷？」(When did you find it? Getting bigger? Pain? Nipple discharge/retraction?) | Covers symptom analysis; red flags for malignancy [1] |
| 1:30–2:30 | Red flags + targeted review – skin changes, weight loss, bone pain, SOB, axillary lumps; menstrual/obstetric Hx | 「皮膚有冇變化，例如凹落去或者橙皮紋？有冇摸到腋下有嘢脹？你月經正唔正常？有冇食荷爾蒙藥？」 | Screens serious disorders; hormonal/reproductive history important for DDx |
| 2:30–3:30 | PMH, FHx, DHx, allergy, social Hx | 「屋企人有冇試過有乳癌或者其他癌症？你有冇長期食開啲咩藥？有冇飲酒食煙？」 | Family Hx of BRCA cancers is high-yield; drug Hx (HRT/OCP) critical [2] |
| 3:30–4:30 | ICE – Ideas, Concerns, Expectations | 「你自己覺得個硬塊係咩嚟？（Idea）你最擔心嘅係咩？（Concern）你嚟睇醫生最希望我可以點樣幫你？（Expectation）」 | Directly tested on Case Report Form; hidden agenda often here |
| 4:30–5:15 | Summarise + physical sign discussion | 「等我總結一下⋯⋯你發現左邊乳房有個硬塊，越嚟越大，冇痛，冇出水，屋企人有乳癌。我想幫你做個乳房檢查，可以嗎？」 | Shows summarising skill; signposts examination |
| 5:15–6:00 | Safety net, plan, empathic close | 「我哋會安排你做三重評估，包括臨床檢查、影像同抽組織。如果有任何新嘢，例如皮膚變化、突然好痛，請即刻返嚟。你有冇嘢想問？」 | Management/safety-net line; checking understanding; empathic closure |
Uncovering the hidden agenda: The patient may present with a breast lump but the real reason for attendance could be fear of cancer (e.g. family member recently diagnosed), worry about body image/relationship, or pressure from a relative. Ask: 「其實今日點解決定嚟睇？係咪有啲嘢特別擔心？」(What actually made you decide to come today? Is there something specific worrying you?)
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Lump onset | When did you first notice the lump? | 「你幾時第一次發現個硬塊？」 | Duration distinguishes acute (abscess) vs chronic (fibroadenoma/cancer) | Rapid onset → abscess/cyst; gradual → fibroadenoma/cancer |
| Lump change | Has it been getting bigger? | 「有冇越嚟越大？」 | Progressive breast lump enlargement is suggestive of malignancy [3] | Cancer; phyllodes tumour |
| Pain | Is it painful? Cyclical? | 「痛唔痛？同月經有冇關係？」 | Cyclical pain → fibrocystic change; non-cyclical → less likely benign | Cyclical mastalgia; abscess if acute |
| Nipple discharge | Any fluid from the nipple? What colour? | 「乳頭有冇出水？咩顏色？」 | Bloody/unilateral nipple discharge = red flag [1] | Intraductal papilloma; DCIS; cancer |
| Nipple changes | Any nipple retraction, eczema-like rash? | 「乳頭有冇凹咗入去？有冇脫皮或者似濕疹？」 | 5Ds of nipple (Deviation, Depression, Dermatitis, Discharge, Discolouration) [4] | Paget's disease; invasive cancer |
| Skin changes | Any dimpling, puckering, orange-peel skin? | 「皮膚有冇凹凹凸凸、橙皮紋？」 | Peau d'orange associated with inflammatory breast cancer [3][5] | Inflammatory breast CA; locally advanced CA |
| Axillary lump | Any lump under your armpit? | 「腋下有冇摸到有硬塊？」 | Axillary lymphadenopathy → metastatic spread | CA breast with nodal metastasis; lymphoma |
| Systemic red flags | Any weight loss, bone pain, shortness of breath? | 「有冇消瘦、骨痛、氣喘？」 | Screen for metastatic disease (bone, lung, liver) | Metastatic breast CA |
| Menstrual Hx | When was your last period? Regular? Menopausal? | 「你最後一次月經係幾時？停咗經未？」 | Pre- vs post-menopausal changes DDx; HRT use | Post-menopausal lump → higher cancer suspicion |
| OCP / HRT | Are you on hormonal pills? | 「有冇食避孕藥或者荷爾蒙補充藥？」 | OCP/HRT increases breast CA risk | Breast cancer |
| Breastfeeding | Are you currently breastfeeding? | 「你而家有冇餵母乳？」 | Lactation → galactocele, lactational abscess | Lactational abscess; galactocele |
| Family Hx | Any family members with breast/ovarian cancer? At what age? | 「屋企人有冇試過乳癌、卵巢癌？幾歲發現？」 | BRCA1/2 – strong FHx is major risk factor [2][6] | Hereditary breast-ovarian CA syndrome |
| Past breast Hx | Any previous breast lumps, biopsies, or surgery? | 「以前有冇試過乳房有硬塊或者做過手術、抽組織？」 | Prior atypical hyperplasia / LCIS increases risk | Recurrence; high-risk patient |
| Social / Functional | How is this affecting your daily life / mood / work? | 「呢件事有冇影響你嘅心情、瞓覺、返工？」 | Biopsychosocial assessment; anxiety/depression screening | Psychological distress; functional impairment |
Case Report Form Answer Builder
Model write-up: "A [age]-year-old [pre/post-menopausal] woman presents with a painless / painful lump in the [L/R] breast for [duration]. The lump has been [static / progressively enlarging]. [No / Yes] associated nipple discharge, skin changes, or nipple retraction. [No / Yes] axillary lump. No systemic symptoms (weight loss, bone pain, SOB). LMP [date]. [No / Yes] use of OCP/HRT. Family history: [mother/sister] diagnosed with breast cancer at age [X]."
Key HPI points: site (quadrant), onset, duration, progression, pain, nipple changes (5Ds), skin changes, axillary swelling, systemic red flags, menstrual status, hormonal drugs, family history.
| Likely RFC | How to Phrase |
|---|---|
| Fear of breast cancer | "The patient attended because she is worried that her breast lump may be cancer." |
| Mother recently diagnosed with breast cancer | "The patient attended because her mother was recently diagnosed with breast cancer, prompting her to seek medical assessment for her own breast lump." |
| Lump is growing | "The patient is concerned about a progressively enlarging breast lump." |
Always link the RFC to the hidden agenda uncovered by ICE questions. The RFC is NOT just "breast lump" – it's why she came today.
| Component | Example Wording |
|---|---|
| Idea | "The patient thinks the lump could be cancer because her aunt had breast cancer." |
| Concern | "She is worried she might need surgery or lose her breast." |
| Expectation | "She hopes the doctor can arrange investigations to confirm whether it is cancer and reassure her." |
In a young woman (< 35): Fibroadenoma – supported by smooth, mobile, non-tender, rubbery lump without skin/nipple changes.
In a middle-aged / post-menopausal woman: Breast carcinoma – supported by hard, irregular, fixed lump with skin tethering/peau d'orange, ± nipple retraction, ± axillary lymphadenopathy.
Choose based on the patient's age, menopausal status, and clinical features in the stem. Triple assessment (clinical + radiological + histopathological) is the gold standard for diagnosis [1][8].
| DDx | Key Discriminator |
|---|---|
| 1. Breast cyst | Smooth, well-defined, fluctuant; sudden onset; USG shows anechoic lesion with posterior enhancement [7] |
| 2. Fibrocystic change | Bilateral lumpiness/nodularity, cyclical mastalgia, pre-menopausal |
| 3. Breast abscess | Acute, red, hot, tender, fluctuant mass; ± fever; often lactating |
(Adjust based on stem: if post-menopausal with hard lump, the most likely Dx is cancer, and DDx shifts to fat necrosis, phyllodes, lymphoma.)
| Domain | Problem |
|---|---|
| Biological | Breast lump requiring triple assessment to exclude malignancy |
| Psychological | Anxiety about cancer diagnosis; fear of mastectomy and body image change |
| Social | Impact on work (time off for investigations); worry about family (children, partner); potential financial burden of treatment |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Breast carcinoma | Hard, irregular, immobile lump with skin tethering / peau d'orange | Palpate lump with flat of fingers – assess consistency, margins, mobility. Ask patient to press hands on hips (tense pectoralis) – lump becomes more fixed if attached to pectoralis. Pinch skin above lump – dimpling if tethered [4] | Stony hard, fixed lump with irregular margins is virtually diagnostic of carcinoma; peau d'orange = lymphatic blockage by tumour [5] |
| Fibroadenoma | Smooth, rubbery, highly mobile lump ("breast mouse") | Palpate – lump slips away under fingers; smooth surface, well-defined margins | High mobility + smooth contour = benign; classic for fibroadenoma |
| Breast cyst | Well-defined, smooth, fluctuant lump; may transilluminate | Palpate for fluctuance; note well-circumscribed margins | Fluctuance suggests fluid-filled lesion; confirmed by USG (anechoic + posterior enhancement) [7] |
| Breast abscess | Red, hot, tender, fluctuant swelling ± pointing | Inspect for erythema, warmth; palpate for fluctuance and tenderness; check temperature | Acute inflammatory signs + fluctuance = abscess; systemic fever supports infection |
| Fat necrosis | Firm, irregular lump ± skin retraction ± ecchymosis | Inspect for ecchymosis; palpate – firm, may mimic cancer | History of trauma is key discriminator; no reliable single sign distinguishes from cancer without biopsy |
Must-Not-Miss Red Flags – Urgent Referral
- Hard, irregular, fixed, painless lump – especially post-menopausal [1][4]
- Peau d'orange / skin dimpling / nipple retraction of recent onset [3][5]
- Bloody unilateral nipple discharge [1]
- Axillary lymphadenopathy with breast lump
- Rapidly enlarging lump (phyllodes tumour / inflammatory CA)
- Eczematous nipple rash unresponsive to treatment → Paget's disease
- Any of the above → urgent referral for triple assessment
Top traps that lose marks:
- Forgetting to ask about family history – BRCA-related cancers (breast, ovarian, prostate, pancreatic) are high-yield and directly tested [2][6].
- Not asking about menstrual / menopausal status – this fundamentally changes the DDx and the choice of imaging (USG for young/dense breasts vs mammography for > 35–40) [1][7].
- Writing "breast lump" as the RFC – the RFC must be the reason she came today, not the symptom. Link it to the concern/trigger.
- Missing psychological impact – examiners specifically mark for biopsychosocial; always ask about mood, sleep, worry, and functional impact.
- Confusing inflammatory breast CA with mastitis – inflammatory CA has peau d'orange, involves ≥1/3 breast, does NOT respond to antibiotics [3][5].
- Mammography is less sensitive in dense breasts (young women, Asians) → prefer USG for young patients [1][7].
- Not mentioning triple assessment – this is the gold standard and appears repeatedly in past papers and GC lectures [1][8].
Shortest safe management/safety-net line:
「我會安排你做三重評估，包括臨床檢查、超聲波或者乳房X光、同埋抽組織化驗。如果期間個硬塊突然大咗好多、皮膚有變化、或者乳頭出血，請即刻返嚟或者去急症室。」
High Yield Summary
What to ASK: Lump characteristics (onset, progression, pain, mobility); nipple changes (5Ds); skin changes (peau d'orange, dimpling); axillary lumps; systemic red flags (weight loss, bone pain); menstrual status; OCP/HRT; family history of breast/ovarian cancer; ICE (especially cancer fear).
What to WRITE: RFC = the trigger/concern, not just "breast lump." Most likely Dx depends on age and features. Always mention triple assessment as the investigation approach. Biopsychosocial must include cancer anxiety and social/functional impact.
What NOT to MISS: Hard fixed painless lump in post-menopausal woman = cancer until proven otherwise. Peau d'orange = inflammatory CA. Bloody nipple discharge = urgent workup. Family history → BRCA counselling. Mammography is less sensitive in dense/young breasts → use USG.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 181. Breast mass breast cancer; benign breast diseases; mammography; breast cancer screening.pdf (pp. 3, 10) [2] Lecture slides: GC 156. Many of my family members have cancers Cancer genetics and cytogenetics (Notes).pdf [3] Past papers: 2025 Fourth Summative MCQ.pdf (Q21, Q23) [4] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (pp. 299, 301) [5] Senior notes: Maksim Surgery Notes.pdf (p. 184 – TNM staging, T4b/T4d) [6] Lecture slides: GC 156. Many of my family members have cancers Cancer genetics and cytogenetics (File 2).pdf [7] Senior notes: Ryan Ho Radiology.pdf (pp. 29, 37–38) [8] Lecture slides: The Managment of breast cancer_Prof A Kwong 20_2_2020.pdf (pp. 9–10)
Back Pain (thoracic)
Thoracic back pain is pain localized to the region between the first and twelfth thoracic vertebrae, often arising from musculoskeletal, degenerative, or, less commonly, serious visceral or structural causes requiring careful evaluation.
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.