NURS 615 Primary Care of Women – TSD 2 – Week 8 case study essay
- T. is a 30 year-old paralegal assistant that came to your clinic because she thinks she has a breast lump in her right breast. She first noticed it 2 weeks ago. It is tender to the touch, and it has decreased in size since her period. There are no changes in the skin over her breast. She denies having fever or chills, and she is not breastfeeding. NURS 615 Primary Care of Women – TSD 2 – Week 8 case study essay
Her medical history is unremarkable. She has never had surgery. She does not smoke, drink or use illicit drugs. She jogs 3 miles daily. She eats a low-fat, low-carbohydrate diet. She is married and has 2 children, ages 3 and 5. Her aunt on her mother’s side had breast cancer at the age of 55.
The physical examination revealed:
General Survey: Alert, anxious-appearing woman, resting comfortably on the exam table.
Vital Signs: BP 128/70 mm Hg; HR 75 bpm and regular; respiratory rate
14 breaths/min; temperature 98.8 F.
Skin: Warm and moist
HEENT: Normocephalic, atraumatic
No occipital, pre-auricular or posterior auricular adenopathy
Neck: Supple, without thyromegaly; no cervical lymphadenopathy
Thorax: Thorax symmetric, with good expansion NURS 615 Primary Care of Women – TSD 2 – Week 8 case study essay
Cardiovascular: Good S1, S2; no S3, S4; no murmurs
Axillae Skin without dimpling or retractions; breast contours
Nipples without scaling or discharge. One freely mobile 3 cm
round circumscribed mass, located in the right upper outer
quadrant; left breast without masses.
Day 1 – Monday, 6/10/2019
- Based on the above history and physical examination, what is your likely primary diagnosis?
- What would you include in your differential diagnosis(es)? Provide rationale for your decision-making based on the literature and the appropriate clinical guidelines?
- Describe how you would discuss the findings of your exam with this patient.
- What would you include in your plan of care for this patient? What further investigations are warranted? (Consider diagnostic testing, laboratory testing, etc.). Include rationale for decision-making based on current clinical guidelines and national recommendations (USTFPS, other) NURS 615 Primary Care of Women – TSD 2 – Week 8 case study essay
Days 2 & 3 – Tuesday, 6/11/2019 & Wednesday, 6/12/2019
Students are required to respond to at least 2 student posts. Review each post and provide evidenced based comments related to each post. If you agree with the diagnosis and differential diagnoses and aspects of the plan, state why and support your decision with evidence from the literature, including national guidelines, national recommendations, and other reliable sources. If you disagree with the aspects of the plan, state why and support your decision with evidence from the literature.
Day 4 – Thursday, 6/13/2019
Provide a brief summary of this clinical experience. Discuss the learning experience and how this will guide your patient interview/history taking in the clinical area.
Student responses should be written in full sentences or clearly written bullets when appropriate; literature citations are required within the context of the case responses as well as in a Reference List at the end of each case, using APA format (using single spacing, sub-headings – separate each post and respond accordingly to each one). This TSD is worth 5 points or 5% of the final grade. Refer to the TSD Grading Rubrics in the Course Syllabus for additional grading criteria. NURS 615 Primary Care of Women – TSD 2 – Week 8 case study essay
The TSD will close at 11:59 pm on Thursday, 6/13/2019. Students that do not submit posts or responses on the required due dates, will be penalized 1 point for each day the assignment is not submitted.
The most likely primary diagnosis is a cyst. Breast cysts are commonly benign and can either be oval or round in shape with edges that are distinct. Cysts occur commonly among women aged 30-50 years but can also occur among post-menopausal women on hormonal therapy (Uzan, Seror & Seror, 2015). The most significant clinical signs that the patient presented with that suggests the likelihood of a breast cyst include: a freely mobile round mass with circumscribed edges and the affected breast area was tender to touch. It is also worth noting that, the client had noted a gradual decrease in the size of the breast mass after her period, a primary characteristic symptom of cysts (Uzan, Seror & Seror, 2015).
The most likely differential diagnoses that I would include are:
- Breast Abscess- this is simply a complication of mastitis that commonly occurs among women who are lactating. If it progresses without necessary intervention, breast tissues necrotize and become an abscess cavity. Patients with breast abscess commonly present with breast tenderness and erythema and a fever (Orr & Kelley, 2016). In comparison, in this case, the patient’s temperatures were within normal range (98.8 F) and neither was she lactating. Thus, this was less likely a breast abscess. NURS 615 Primary Care of Women – TSD 2 – Week 8 case study essay
- Hematoma- hematomas usually develop immediately following a trauma or surgery. Hematomas that are hyper acute are likely to appear as simple cysts, round with walls that are distinct (Neal et al., 2014). However, since the patient had no recent history of surgery or trauma, the diagnosis of a hematoma is less likely.
- Galactocele- Galactoceles usually form when milk that is distal to an obstruction in the terminal duct accumulates. They are usually either round, oval and circumscribed. Most patients who develop Galactoceles can also develop superimposed infections thereby need drainage (Orr & Kelley, 2016). They can however resolve on their own when conservatively managed. However, it is clear that neither was this patient breastfeeding not report of a breast discharge (milk). Thus, the likelihood that this was a Galactocele is minimal.
I will start by telling the patient what is normal. This includes the color of the skin overlying the breasts, bilateral breast sizes, appearance of the areola and no breast discharge. I will then progress to explain to the patient the abnormal findings based on inspection and palpation. However, I will let the patient know that despite the abnormal findings, there is nothing to be anxious/worry about but rather consider the findings (cyst) as a common breast condition among young women of reproductive age still having their periods (Orr & Kelley, 2016). I will however insist and educate the patient on the need to perform regular self-breast exams and go for routine screening (breast cancer) basing on the fact that she has a positive family history of a maternal aunt who had breast cancer.
The patient’s plan of care would include conducting a breast ultrasound which will help to determine whether the mass is filled with either fluid or solid. If fluid filled, this will confirm the diagnosis of a cyst (Neal et al., 2014). Otherwise, a solid mass would be confirmed to be benign as either a fibro adenoma or cancerous. If the mass can easily be felt, an ultrasound guided fine needle aspiration can be done. Fluid filled in the lump can be aspirated. When the mass happens to immediately go away, the diagnosis of a breast cyst can be confirmed (Neal et al., 2014). The patient will be informed thereafter on the need to continue performing self-breast exams to know when new cysts develop and have them drained since it is common for cysts to recur. Since the patient’s symptoms are less severe, she will be advised not to use hormone therapy based on the probable side effects they can cause. Conservatively, the patient will be advised to use ice packs for pain relief, to wear bras that are well-fitted and supportive to avoid discomfort, reconsider eliminating caffeine from her diet and use of over the counter medications such as ibuprofen or naproxen for pain relief (Neal et al., 2014). NURS 615 Primary Care of Women – TSD 2 – Week 8 case study essay
Neal, L., Sandhu, N. P., Hieken, T. J., Glazebrook, K. N., Mac Bride, M. B., Dilaveri, C. A.,& Visscher, D. W. (2014, April). Diagnosis and management of benign, atypical, and indeterminate breast lesions detected on core needle biopsy. In Mayo Clinic Proceedings (Vol. 89, No. 4, pp. 536-547). Elsevier.
Orr, B., & Kelley Iii, J. L. (2016). Benign breast diseases: evaluation and management. Clinical obstetrics and gynecology, 59(4), 710-726.
Uzan, C., Seror, J. Y., & Seror, J. (2015). Management of a breast cystic syndrome: Guidelines. Journal de gynecologie, obstetrique et biologie de la reproduction, 44(10), 970-979. NURS 615 Primary Care of Women – TSD 2 – Week 8 case study essay