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By P D Chan, Susan M. Johnson

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The breasts should be inspected for asymmetry, deformity, skin retraction, erythema, peau d'orange (indicating breast edema), and nipple retraction, discoloration, or inversion. B. Palpation 1. The breasts should be palpated while the patient is sitting and then supine with the ipsilateral arm extended. The entire breast should be palpated systematically. 2. The mass should be evaluated for size, shape, tex­ ture, tenderness, fixation to skin or chest wall. The location of the mass should be documented with a diagram in the patient’s chart.

The patient should be asked to record symptoms prospectively for two months. If the patient fails to demonstrate a symptom free interval in the follicular phase, she should be evaluated for a mood or anxiety disorder. II. Treatment of premenstrual dysphoric disorder A. Serotonin reuptake inhibitors 1. Fluoxetine (Sarafem) is an effective treatment for PMDD when given in a daily dose of 20 mg/day. The response rate is 60 to 75 percent. The most common reasons for failure to continue the treat­ ment are headache, anxiety, and nausea.

Ultrasonography or aspiration must establish a definitive diagnosis for a cyst. Cysts require surgical biopsy if the aspirated fluid is bloody, the palpable abnormality does not resolve completely after the aspiration of fluid or the same cyst recurs multiple times in a short period of time. Routine cytologic examination of cyst fluid is not indicated. 3. Nonpalpable cysts identified by mammography and confirmed to be simple cysts by ultrasound examina­ tion require no treatment. C. Solid Breast Masses 1.

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