Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with a localized, painful, erythematous, and indurated breast mass. Associated symptoms include fever, chills, and purulent nipple discharge. Duration of symptoms: [X] days. History of recent mastitis, lactation status, or prior breast procedures noted.
Clinical Examination Findings
Physical exam reveals a tender, fluctuant, erythematous mass in the [Quadrant] of the [Right/Left] breast. Skin overlying the lesion is warm to touch with possible peau d'orange or ulceration. Axillary lymphadenopathy noted/absent. Systemic signs: Temperature [X]°C, Tachycardia present/absent.
Treatment Protocol
Plan: 1. Ultrasound-guided needle aspiration or surgical incision and drainage (I&D) as indicated. 2. Obtain culture and sensitivity of purulent aspirate. 3. Initiate empiric antibiotic therapy (e.g., Dicloxacillin or Clindamycin). 4. Analgesia and warm compresses. 5. Follow-up in [X] days to assess wound healing.