Diagnostic Tests for Paget's Disease
Paget's Disease Tests: Book Excerpts
Home Diagnostic Testing
These home medical tests may be relevant to Paget's Disease:
- Colon & Rectal Cancer: Home Testing
- Menopause: Related Home Testing:
- Vaginal Health: Home Testing:
- Breast Cancer: Related Home Tests:
- Cancer-Related Home Testing:
Paget's Disease Diagnosis: Book Excerpts
Diagnostic Tests for Paget's Disease: Online Medical Books
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BREAST DISCHARGE:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
If there is a bloody discharge, one should not hesitate to refer the patient to a general surgeon, who will probably order mammography and perform a biopsy. The type of biopsy may be either a fine-needle aspiration or fine-needle biopsy or excisional biopsy, but the general surgeon can decide which is appropriate for any given patient. A unilateral nonbloody discharge may be studied further by ordering tests for occult blood, cytology, and mammography before referral. Remember that exploratory surgery may be the only way to get a diagnosis.
If the discharge is bilateral and milky, a serum prolactin should be ordered. If the prolactin is high, referral to an endocrinologist is probably the best step to take next. The endocrinologist will probably order a CT scan of the brain and pituitary and do further workup studies based on his examination.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Nipple discharge:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient when she first noticed the discharge, and determine its duration, extent, quantity, color, consistency, and smell, if any. Has she had other nipple and breast changes, such as pain, tenderness, itching, warmth, changes in contour, and lumps? If she reports a lump, question her about its onset, location, size, and consistency.
Obtain a complete gynecologic and obstetric history, and determine her normal menstrual cycle and the date of her last period. Ask if she experiences breast swelling and tenderness, bloating, irritability, headaches, abdominal cramping, nausea, or diarrhea before or during menses. Note the number, date, and outcome of her pregnancies and, if she breast-fed, the approximate time of her last lactation. Also, check for risk factors of breast cancer — family history, previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, or late menopause.
Start your physical examination by characterizing the discharge. If the discharge isn’t frank, try to elicit it. (See Eliciting nipple discharge.) Then examine the nipples and breasts with the patient in four different positions: sitting with her arms at her sides; with her arms overhead; with her hands pressing on her hips; and leaning forward so her breasts are suspended. Check for nipple deviation, flattening, retraction, redness, asymmetry, thickening, excoriation, erosion, or cracking. Inspect her breasts for asymmetry, irregular contours, dimpling, erythema, and peau d’orange. With the patient in a supine position, palpate the breasts and axillae for lumps, giving special attention to the areolae. Note the size, location, delineation, consistency, and mobility of any lump you find.
Is the patient taking hormones (hormonal contraceptives or hormone replacement therapy)? Is the discharge spontaneous, or does it have to be expressed?
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Breast nodule [Breast lump]:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient reports a lump, ask her how and when she discovered it. Does the size and tenderness of the lump vary with her menstrual cycle? Has the lump changed since she first noticed it? Has she noticed other breast signs, such as a change in breast shape, size, or contour; a discharge; or nipple changes?
Is she breast-feeding? Does she have fever, chills, fatigue, or other flulike signs or symptoms? Ask her to describe any pain or tenderness associated with the lump. Is the pain in one breast only? Has she sustained recent trauma to the breast?
Explore the patient's medical and family history for factors that increase her risk of breast cancer. These include a high-fat diet, having a mother or sister with breast cancer, or having a history of cancer, especially cancer in the other breast. Other risk factors include nulliparity and a first pregnancy after age 30.
CULTURAL CLUE: Breast cancer incidence and mortality are about five times higher in North America and northern Europe than in Asia and Africa.
Next, perform a thorough breast examination. Pay special attention to the upper outer quadrant of each breast, where one-half of the ductal tissue is located. This is the most common site of malignant breast tumors.
Carefully palpate a suspected breast nodule, noting its location, shape, size, consistency, mobility, and delineation. Does the nodule feel soft, rubbery, and elastic or hard? Is it mobile, slipping away from your fingers as you palpate it, or firmly fixed to adjacent tissue? Does the nodule seem to limit the mobility of the entire breast? Note the nodule's delineation. Are the borders clearly defined or indefinite? Does the area feel more like a hardness or diffuse induration than a nodule with definite borders?
Do you feel one nodule or several small ones? Is the shape round, oval, lobular, or irregular? Inspect and palpate the skin over the nodule for warmth, redness, and edema. Palpate the lymph nodes of the breast and axilla for enlargement.
Observe the contour of the breasts, looking for asymmetry and irregularities. Be alert for signs of retraction, such as skin dimpling and nipple deviation, retraction, or flattening. (To exaggerate dimpling, have your patient raise her arms over her head or press her hands against her hips.) Gently pull the breast skin toward the clavicle. Is dimpling evident? Mold the breast skin and again observe the area for dimpling.
Be alert for a nipple discharge that's spontaneous, unilateral, and nonmilky (serous, bloody, or purulent). Be careful not to confuse it with the grayish discharge that can be elicited from the nipples of a woman who has been pregnant. (See Breast nodule: Common causes and associated findings, page 106.)
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Nipple discharge:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient when she first noticed the discharge, and determine its duration, extent, quantity, color, consistency, and smell, if any. Has she had other nipple and breast changes, such as pain, tenderness, itching, warmth, changes in contour, and lumps? If she reports a lump, question her about its onset, location, size, and consistency.
Obtain a complete gynecologic and obstetric history, and determine her normal menstrual cycle and the date of her last menses. Ask if she experiences breast swelling and tenderness, bloating, irritability, headaches, abdominal cramping, nausea, or diarrhea before or during menses. Note the number, date, and outcome of her pregnancies and, if she breast-fed, the approximate time of her last lactation. Also, check for any risk factors of breast cancer—family history, previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, or late menopause.
Start your physical examination by characterizing the discharge. If the discharge isn’t frank, try to elicit it. (See Eliciting nipple discharge.) Then examine the nipples and breasts with the patient in four different positions: sitting with her arms at her sides; with her arms overhead; and with her hands pressing on her hips; and leaning forward so her breasts are suspended. Check for nipple deviation, flattening, retraction, redness, asymmetry, thickening, excoriation, erosion, or cracking. Inspect her breasts for asymmetry, irregular contours, dimpling, erythema, and peau d’orange. With the patient in a supine position, palpate the breasts and axillae for lumps, giving special attention to the areolae. Note the size, location, delineation, consistency, and mobility of any lump you find.
Is the patient taking hormones (hormonal contraceptives or hormone replacement therapy)? Is the discharge spontaneous, or does it have to be expressed?
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Breast nodule [Breast lump]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If your patient reports a lump, ask her how and when she discovered it and whether its size and tenderness vary with her menstrual cycle. Has the lump changed since she first noticed it? Has she noticed any other breast signs, such as a change in breast shape, size, or contour; a discharge; or nipple changes?
Is she breast-feeding? If so, does she have fever, chills, fatigue, or other flulike signs or symptoms? Ask her to describe any pain or tenderness associated with the lump. Is the pain in one breast only? Has she sustained recent trauma to the breast?
Explore the patient’s medical and family history for factors that increase her risk of breast cancer. These include a high-fat diet, having a mother or sister with breast cancer, or having a history of cancer, especially cancer in the other breast. Other risk factors include nulliparity and a first pregnancy after age 30.
Cultural Cue: Breast cancer incidence and mortality are about five times higher in North America and northern Europe than in Asia and Africa.
Next, perform a thorough breast examination. Pay special attention to the upper outer quadrant of each breast, where one-half of the ductal tissue is located. This is the most common site of malignant breast tumors.
Carefully palpate a suspected breast nodule, noting its location, shape, size, consistency, mobility, and delineation. Does the nodule feel soft, rubbery, and elastic or hard? Is it mobile, slipping away from your fingers as you palpate it, or firmly fixed to adjacent tissue? Does the nodule seem to limit the mobility of the entire breast? Note the nodule’s delineation. Are its borders clearly defined or indefinite? Does the area feel more like a hardness or diffuse induration than a nodule with definite borders?
Do you feel one nodule or several small ones? Is the shape round, oval, lobular, or irregular? Inspect and palpate the skin over the nodule for warmth, redness, and edema. Palpate the lymph nodes of the breast and axilla for enlargement.
Observe the contour of the breasts, looking for asymmetry and irregularities. Be alert for signs of retraction, such as skin dimpling and nipple deviation, retraction, or flattening. (To exaggerate dimpling, have your patient raise her arms over her head or press her hands against her hips.) Gently pull the breast skin toward the clavicle. Is dimpling evident? Mold the breast skin and again observe the area for dimpling.
Be alert for a nipple discharge that’s spontaneous, unilateral, and nonmilky (serous, bloody, or purulent). Be careful not to confuse it with the grayish discharge that can be elicited from the nipples of a woman who has been pregnant. (See Breast nodule: Causes and associated findings.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Nipple Discharge:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Clinical breast examination (Chapter 11.2)
1. Inspection. Observe the skin of the breast for crusting or a rash on the nipple or areolar region. Document the color of any discharge. Look for evidence of nipple retraction. Locate the site of the discharge on the nipples. Magnification can assist localization. Look for chest wall scars, evidence of viral infections (e.g., herpes zoster or simplex), and signs of eczema or inflammation.
2. Palpation. Feel the skin surface for warmth in the presence of erythema. Palpate both breasts for evidence of a mass or tenderness. Palpate regional nodes for evidence of lymphadenopathy (Chapters 11.2 and 15.2).
3. Compression. Compress the nipple and areolar area of both breasts with the thumb and index finger in an effort to elicit a discharge. Perform this examination in several directions. Note the location of any discharge and the number of ducts involved, as well as whether the discharge is unilateral or bilateral.
B. Other examination components. Palpate the thyroid and liver if history indicates the need. Perform a neurologic examination, including visual fields, in patients with visual disturbance or headache.
Testing
A. Clinical laboratory. Order blood tests looking for evidence of thyroid, renal, and liver diseases or establishing a prolactin level, based on clinical history.
B. Discharge. Test for occult blood if blood is not readily apparent. The specificity and sensitivity of cytology limits its effectiveness and is not necessary.
C. Imaging. Mammography is indicated to look for nonpalpable masses or calcifications. Ductography may help distinguish the location of ductal pathology in a localized discharge but is not a substitute for exploration of the ductal system.
D. Ductal exploration. The patient who does not have a good physiologic explanation for her discharge should be referred for surgical exploration or biopsy.
Diagnostic assessment (1,2)
A. Categories of risk. The four categories of risk described by Arnold and Neiheisel include lactation, physiologic, pathologic, and false discharge (1).
1. Physiologic discharges are usually bilateral, multiductal, painless, and associated with either stimulation of the nipple or medications. Color may be white, yellow, gray, or green, and the consistency is usually milky. Occasionally, blood is present.
2. Pathologic discharges are usually unilateral, uniductal, and spontaneous. Color is variable and blood or purulence may be apparent. Cancer, benign tumors, infections, and systemic disease are pathologic causes of discharges of this type.
3. Pseudodischarge. A false discharge is often associated with staining on clothing or crusting on the nipple. This is different from the “droplets” of a true discharge. Eczema, viral infections (herpes zoster or simplex), or Paget’s disease can cause a pseudodischarge.
B. Specific disorders of interest
1. Intraductal papilloma is the most common cause of benign pathologic discharges.
2. Ductal ectasia is the result of a progression of ductal stagnation and resultant inflammatory process. The incidence of this disorder is higher in smokers and is most prominent in those aged 40 to 60 years. Induration and noncyclic burning pain are characteristic of this disorder.
3. Paget’s disease involves the skin of the nipple and areola. It is usually associated with ductal carcinoma. Send any areolar lesion that does not respond to antibiotics or topical treatment for biopsy to exclude this disorder.
References
1. Arnold G, Neiheisel M. A comprehensive approach to evaluating nipple discharge. Nurse Pract 1997;22(7):96–108.
2. Andolsek K, Copeland J. Conditions of the breast. In: Taylor RB, ed. Family medicine: principles and practice, 5th ed. New York: Springer-Verlag, 1998.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Breast Mass/Discharge:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Breast Mass: Breast lumps should be approached with a high index of suspicion for breast cancer, as approximately 20% of solitary or dominant breast masses are breast cancers. The physical examination is an important part of the diagnostic “triple test,” which includes mammography and fine needle aspiration cytology. When all three are positive, 99.4% have breast cancer. When all three tests suggest a benign lesion, only 0.7% have breast cancer.
Screening clinical breast examination detects approximately 50% of breast cancers. There is some but not total overlap with mammography; about 10% of screen-detected cancers are detected by physical examination and missed by mammography, while about 40% are detected by mammography and missed by physical examination. Techniques which increase the sensitivity of the examination include flattening of the breast against the chest wall (arm overhead), circular motions using the pads of the fingers, and spending greater time with the examination.
Cyclical pain and tenderness are usually due to fibrocystic disease. Although breast cancer can present with pain, it is often atypical and there is usually no tenderness. Characteristics of pain with alternative diagnoses include the following: heavy or full of milk (fibrocystic), sharp and radiating (radiculitis), itching, burning, drawing (duct ectasia), burning and stinging (mastodynia), sore, bruised, stabbing (trauma), throbbing (infectious), aching, and locally tender (costochondritis). Benign cysts are more prominent premenstrually and become smaller during the follicular phase of the menstrual cycle. Palpation characteristics suggestive of cancer include a mass that is firm, has indistinct borders, and has attachments to the skin or deep fascia. Dimpling of the skin, retraction of the nipple, bloody discharge from the nipple, and axillary nodal enlargement are all important clues to breast cancer.
Breast Discharge: Galactorrhea occurs when high levels of prolactin act upon a breast primed by estrogen and progesterone. Therefore, it is extremely rare in men unless there is a feminizing state. Milky discharge can usually be visually differentiated from a serous or bloody discharge. If confirmation is needed, microscopic examination for oval fat bodies (or use of Sudan stain) can be performed.
Bloody discharge is due to an ductal carcinoma (in situ or invasive) in one third of patients, a bleeding intraductal papilloma in another third, and fibrocystic breasts with an intraductal component (e.g. ductal ectasia, intraductal hyperplasia) in the remainder. All require further evaluation. When expressed by exam, discharge coming from one duct is more worrisome than discharge from multiple ducts. Bilateral multiductal discharge that is guaiac negative is usually benign regardless of color (milky, brown, green, yellow, blue, or clear), and due to an endocrine or physiologic process.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Nipple discharge:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Start your physical assessment by characterizing the discharge. If the discharge isn’t frank, try to elicit it. (See Eliciting nipple discharge.) Then examine the nipples and breasts with the patient in four different positions: sitting with her arms at her sides; with her arms overhead; with her hands pressing on her hips; and leaning forward so her breasts are suspended. Check for nipple deviation, flattening, retraction, redness, asymmetry, thickening, excoriation, erosion, or cracking. Inspect her breasts for asymmetry, irregular contours, dimpling, erythema, and peau d’orange. With the patient in a supine position, palpate the breasts and axillae for lumps, giving special attention to the areolae. Note the size, location, delineation, consistency, and mobility of any lump you find.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Breast nodule:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Perform a thorough breast examination. Pay special attention to the upper outer quadrant of each breast, where one-half of the ductal tissue is located. This is the most common site of malignant breast tumors.
Carefully palpate a suspected breast nodule, noting its location, shape, size, consistency, mobility, and delineation. Does the nodule feel soft, rubbery, and elastic or hard? Is it mobile, slipping away from your fingers as you palpate it, or firmly fixed to adjacent tissue? Does the nodule seem to limit the mobility of the entire breast? Note the nodule’s delineation. Are the borders clearly defined or indefinite? Does the area feel more like a hardness or diffuse induration than a nodule with definite borders?
Do you feel one nodule or several small ones? Is the shape round, oval, lobular, or irregular? Inspect and palpate the skin over the nodule for warmth, redness, and edema. Palpate the lymph nodes of the breast and axilla for enlargement.
Observe the contour of the breasts, looking for asymmetry and irregularities. Be alert for signs of retraction, such as skin dimpling and nipple deviation, retraction, or flattening. (To exaggerate dimpling, have your patient raise her arms over her head or press her hands against her hips.) Gently pull the breast skin toward the clavicle. Is dimpling evident? Mold the breast skin and again observe the area for dimpling.
Be alert for a nipple discharge that’s spontaneous, unilateral, and nonmilky (serous, bloody, or purulent). Be careful not to confuse it with the grayish discharge that can be elicited from the nipples of a woman who has been pregnant.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Nipple discharge:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient when she first noticed the discharge, and determine its duration, extent, quantity, color, consistency, and smell, if any. Is the discharge spontaneous or does it have to be expressed? Has she had other nipple and breast changes, such as pain, tenderness, itching, warmth, changes in contour, and lumps? If she reports a lump, question her about its onset, location, size, and consistency. Ask about other symptoms, such as fever and malaise.
Obtain a complete gynecologic and obstetric history, and determine her normal menstrual cycle and the date of her last menses. Ask if she experiences breast swelling and tenderness, bloating, irritability, headaches, abdominal cramping, nausea, or diarrhea before or during menses. Note the number, date, and outcome of her pregnancies and, if she breast-fed, the approximate time of her last lactation. Also, check for risk factors of breast cancer—family history, previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, or late menopause.
Is the patient taking hormones (such as hormonal contraceptives or hormone replacement therapy), antihypertensives, or psychotropic drugs?
Start your physical examination by characterizing the discharge. If the discharge isn't frank, try to elicit it. (See Eliciting nipple discharge.) Then examine the nipples and breasts with the patient in four different positions: sitting with her arms at her sides; with her arms overhead; with her hands pressing on her hips; and leaning forward so her breasts are suspended. Check for nipple deviation, flattening, retraction, redness, asymmetry, thickening, excoriation, erosion, or cracking. Inspect her breasts for asymmetry, irregular contours, dimpling, erythema, and peau d'orange. With the patient in a supine position, palpate the breasts and axillae for lumps, giving special attention to the areolae. Note the size, location, delineation, consistency, and mobility of any lump you find.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Breast nodule [Breast lump]:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient reports a lump, ask her how and when she discovered it. Does the size and tenderness of the lump vary with her menstrual cycle? Has the lump changed since she first noticed it? Has she noticed other breast signs, such as a change in breast shape, size, or contour; a discharge; or nipple changes?
Is she breast-feeding? Does she have fever, chills, fatigue, or other flulike signs or symptoms? Ask her to describe any pain or tenderness associated with the lump. Is the pain in one breast only? Has she sustained recent trauma to the breast?
Explore the patient's medical and family history for factors that increase her risk of breast cancer. These include having a mother or sister with breast cancer or having a history of cancer, especially cancer in the other breast. Other risk factors include nulliparity and a first pregnancy after age 30.
Next, perform a thorough breast examination. Pay special attention to the upper outer quadrant of each breast, where one-half of the ductal tissue is located. This is the most common site of malignant breast tumors.
Carefully palpate a suspected breast nodule, noting its location, shape, size, consistency, mobility, and delineation. Does the nodule feel soft, rubbery, and elastic or hard? Is it mobile, slipping away from your fingers as you palpate it, or firmly fixed to adjacent tissue? Does the nodule seem to limit the mobility of the entire breast? Note the nodule's delineation. Are the borders clearly defined or indefinite? Does the area feel more like a hardness or diffuse induration than a nodule with definite borders?
Do you feel one nodule or several small ones? Is the shape round, oval, lobular, or irregular? Inspect and palpate the skin over the nodule for warmth, redness, and edema. Palpate the lymph nodes of the breast and axilla for enlargement.
Observe the contour of the breasts, looking for asymmetry and irregularities. Be alert for signs of retraction, such as skin dimpling and nipple deviation, retraction, or flattening. (To exaggerate dimpling, have your patient raise her arms over her head or press her hands against her hips.) Gently pull the breast skin toward the clavicle. Is dimpling evident? Mold the breast skin and again observe the area for dimpling.
Be alert for a nipple discharge that's spontaneous, unilateral, and nonmilky (for example, serous, bloody, or purulent). Be careful not to confuse it with the grayish discharge that can be elicited from the nipples of a woman who has been pregnant.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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