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The most common breast complaints in the ED involve breast pain, breast mass, nipple discharge, infection, or postoperative complications. Although the problems are rarely emergent except when systemic symptoms such as fever are present, concern for the potential of breast cancer may contribute to increased patient anxiety.

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Few data are available regarding the incidence of emergency presentations of general breast disorders. Approximately one in every three to four women in the U.S. sees a physician with a chief complaint relating to the breasts.1 Current epidemiology of the emergency presentation of breast problems has not been recently reported in the U.S.2 In Spain, complaints secondary to breast cancer account for approximately 15% of all oncologic emergency visits, or 5% of total emergency visits.3 Women in the U.S. have a 12% lifetime risk of developing breast cancer.2 In 2008, the incidence of all breast cancers exceeded 182,000 new cases, with an estimated 40,480 deaths attributable to breast cancer. Although the acuity of the breast complaints may be low, the prevalence of presenting breast disorders can be quite high.

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Normal breast tissue is a circular mass of glandular tissue located on the anterior chest wall and extending from the sternocostal junction medially to the midaxillary line laterally and from the second to the sixth ribs in the midclavicular line. Sensory innervation is dermatomal in distribution, whereas the arterial supply to the breast arises from the internal mammary, lateral thoracic, thoracodorsal, and subscapular arteries. Lymphatic drainage of the breast is primarily to the axilla, with a small portion going to internal mammary lymph nodes. Lymph flow is not regionally distributed; lymphatic drainage to either the axilla or the internal mammary chain can originate in any quadrant of the breast.

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Stromal and lobular tissues continue to develop until approximately 25 years of age. Adult breast is composed of approximately 20% ductal tissue, and the remaining breast volume consists of fat and connective tissue that give the breast its characteristic texture and shape.

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Cyclic variances in estrogens, progesterone, follicle-stimulating hormone, and luteinizing hormone signal stromal and glandular changes in breast physiology. For example, rising levels of circulating progesterone and a small peak in estrogen levels result in interlobular edema and cause the breast swelling, engorgement, and tenderness associated with the premenstrual phase. Breast tissue volume and tenderness are at a minimum 5 to 7 days after menstruation due to the relative lack of progesterone, which allows for a more comfortable breast examination. The rapid decline in estrogen and progesterone levels at the onset of menstruation leads to ductal involution. At menopause, glandular tissue is lost secondary to the gradual loss of estrogen and progesterone synthesis. The resulting postmenopausal breast consists predominantly of prepectoral fat, connective tissue, mammary ducts, and minimal lobular elements.

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History and Physical Examination

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The history taking and examination should be as private, comfortable, and reassuring as ...

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