Mother With Her Children
Hippolyte Paul Delaroche
August 2012, Denver. Late one snowy day in Denver, a 57-year-old Caucasian,
vagabond woman, Ms. Jane Nomad, presents to your emergency department with a
firm, painless mass in her left breast. Due to the down turn in the economy,
health insurance has not been a top priority. She has not seen a physician in 6
years. She reports that she has been feeling fine, but her new boyfriend
insisted that she seek medical attention because he cares.
Social history: Ms. Nomad smoked two packs of cigarette a
week, for the last thirty years. Drinks alcohol, a six-pack every couple of
days and used a variety of illicit drugs since leaving home 40 years ago. She
has had five, successful vaginally delivered, pregnancies, consisting of three
boys and two girls, all with different fathers. She believes her left breast
has not stopped lactating since her last pregnancy at age 41. She recalls no
family or surgical history.
Physical exam reveals an obese 5’2” woman weighing 165 lbs.
She is alert and oriented times three. Oral temperature is 98.2 F, pulse 88,
respirations 20. Her breath and heart sounds are normal. Visual inspection of
the left breast: reveals some asymmetry as compared to the right, the skin shows
no erythema or ulceration. The patient’s left nipple is inverted slightly
medial when compared to her right. You palpate a ill-defined mass in the left
breast, upper outer quadrant that is approximately two centimeters, in diameter
and moderately tender to your touch. Her left bra cup appears lightly stained
What do you do next?