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Ms. Rachael Hardy is a 42-year-old woman who presents with two self-detected breast lumps. She had a prior breast biopsy three years ago that identified an atypical ductal hyperplasia. She denies breast discharge, bleeding, overlying skin changes, lymphadenopathy, fevers or past breast trauma. She reports an 11-pound weight loss due to diminished appetite over the last three months. Her mother was diagnosed with breast cancer at age 48 (I-Human, n.d.).
Discuss the questions that would be important to include when interviewing a patient with this issue.
Inquire about pain. Note onset, duration, location, and relation to menstrual period and if pain is constant or intermittent? What has the patient tried to alleviate the pain? Note what has worked. Inquire about the patient’s family history of breast pain, lumps, or cancer. Has there been trauma such as being hit or having rough experience during sex? Do her breasts hurt during or after exercise such as running, aerobics, soccer, or basketball? Does she wear a good, supporting, properly fitted bra generally and for sports? Has she had any breast surgery or biopsy? Note medication history such as oral contraceptives or phenytoin (Cash & Glass, 2014).
Describe the clinical findings that may be present in a patient with this issue.
Upon inspection the breasts may have masses; dimples; changes in the skin; and/or changes in the way the nipples are pointed (Cash & Glass, 2014).
Upon palpation of the breasts there could be hard, fixed, or cystic masses in the breast, under the nipple, in the tail of the breast, and in the axilla; also nipple discharge may be also present (Cash & Glass, 2014).
In this case the physical exam revealed a palpable 2.5 cm mass in the upper-inner quadrant of the right breast at the 2 o’clock position and a 2-cm, right-breast mass at the 12 o’clock position. A hard, mobile, right-axillary lymph node was also palpable (I-human, n.d.).
Are there any diagnostic studies that should be ordered on this patient? Why?
Diagnostic tests may include: a mammogram; an ultrasonography to differentiate cystic from solid masses; an MRI may be useful for detecting tissues with increased blood flow but limited by false positive results; a fine needle aspiration and biopsy; and/or an excisional biopsy for solid lumps (Cash & Glass, 2014).
List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each.
Primary Diagnosis: Breast mass/lump, neoplastic: there is evidence upon physical examination of the presence of two breast lumps. The mammogram was abnormal and highly suspicious for breast cancer with three masses detected and an enlarged right axillary lymph node. The breast biopsy was positive for invasive ductal carcinoma and the lymph node biopsy is positive for metastatic breast adenocarcinoma (I-Human, n.d.).
Three Secondary Diagnoses:
1- Fibroadenoma: usually regress after menopause and generally present as a well-defined mobile mass smooth and hard like a marble on physical examination or a well-defined solid mass on ultrasound (McCance & Huether, 2013).
2- Fibrocystic disease (breast cysts): Cysts, which are fluid-filled sacs, feel soft, baggy when they occur close to the surface of the breast but when deeply implanted they can feel hard. The frequency of fibrocystic lesions is probably associated to hormonal changes, which are also affected by genetics, age, parity, history of lactation, caffeine consumption, and use of exogenous hormones (LeMone, Burke & Bauldoff, 2011).
3- Breast Lipoma: Lipomas are benign mesenchymal tumors that develop in areas of abundant adipose tissue and usually develop as well-circumscribed, encapsulated masses with a doughy feel that is freely mobile underneath the skin (Ramírez-Montaño, Vargas-Tellez, Dajer-Fadel & Espinosa Maceda, 2013).
Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.
Referral for surgical, radiation, and medical oncology for mastectomy and radiation therapy seems the best approach for this patient. But a referral to a psychologist and a support group is also appropriate in this case because a person diagnosed with cancer may exhibit a variety of psychologic and emotional responses. Some of them see it as a death sentence, experiencing overwhelming grief and sometimes giving up hope. Others, feel guilt and consider cancer a punishment for past behaviors. Common emotions are grief, anger, powerlessness, fear, isolation, and concerns about body image and sexual dysfunction (LeMone, Burke & Bauldoff, 2011). During the process of cancer diagnoses, treatment, and recovery, we, as health care professionals have the vital responsibility of providing these patients support and managing their physical and emotional responses through the disease process and treatment.
References:
Cash, J. C. & Glass, Ch. A. (2014). Family Practice Guidelines, 3rd Edition. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/boo…
I-Human. (n.d.). Case Player: Rachael Hardy V3 PC. Retrieved from: https://app.i-human.com/player?env=production&play…
LeMone, P., Burke, K., Bauldoff, G. (2011). Medical Surgical Nursing. Critical Thinking in Patient Care. (5th Ed.). Pearson.
McCance, K. & Huether, S. (2013). Pathophysiology: The Biologic Basis for Disease in Adults and Children, (7th Ed).
Ramírez-Montaño, L., Vargas-Tellez, E., Dajer-Fadel, W. L., & Espinosa Maceda, S. (2013). Giant Lipoma of the Breast. Archives of Plastic Surgery, 40(3), 244–246.
Expert Solution Preview
Introduction:
In this scenario, a 42-year-old female patient presents with self-detected breast lumps and weight loss over the last three months. A prior breast biopsy identified an atypical ductal hyperplasia. The medical professor is asked to discuss the important questions that should be asked during the patient interview, clinical findings that may be present, diagnostic tests that should be ordered, primary diagnosis, differential diagnoses, and management plan for the patient.
1. Discuss the questions that would be important to include when interviewing a patient with this issue.
During the patient interview, it is important to inquire about pain onset, duration, location, relation to menstrual period, and if pain is constant or intermittent. It is also important to inquire about the patient’s family history of breast pain, lumps, or cancer. Trauma such as being hit or having rough experience during sex should be assessed. Breasts hurting during or after physical exercise and use of a good, supporting, properly fitted bra should also be discussed. Any history of breast surgery or biopsy and medication history such as oral contraceptives or phenytoin should be noted.
2. Describe the clinical findings that may be present in a patient with this issue.
Upon inspection of the breasts, masses, dimples, changes in the skin, and changes in the way the nipples are pointed could be present. Upon palpation of the breasts, hard, fixed or cystic masses in the breast, under the nipple, in the tail of the breast, and in the axilla may be present. Nipple discharge may also be present.
3. Are there any diagnostic studies that should be ordered on this patient? Why?
Diagnostic studies that should be ordered on this patient include mammogram, ultrasonography to differentiate cystic from solid masses, MRI for detecting tissues with increased blood flow, fine needle aspiration, biopsy, and excisional biopsy for solid lumps. These tests are ordered to determine the size and location of the lumps and to differentiate between benign and malignant tumors.
4. List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each.
The primary diagnosis for this patient is breast mass/lump, neoplastic, as there is evidence of the presence of two breast lumps, mammogram is abnormal, and biopsy is positive for invasive ductal carcinoma and metastatic breast adenocarcinoma. The differential diagnoses for this patient could be fibroadenoma, fibrocystic disease, and breast lipoma. Fibroadenoma presents as a well-defined mobile mass on physical examination or a well-defined solid mass on ultrasound and generally regresses after menopause. Fibrocystic disease is associated with fluid-filled sacs that feel soft when close to the surface of the breast but hard when deeply implanted. Breast lipoma is a benign tumor that develops as a well-circumscribed, encapsulated mass with a doughy feel that is freely mobile underneath the skin.
5. Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.
The management plan for this patient includes referral to surgical, radiation, and medical oncology for mastectomy and radiation therapy. Referral to a psychologist and support group is also appropriate to manage the patient’s emotional and psychological responses. The patient should be educated on the importance of regular mammograms and self-breast examinations. Follow-ups should be scheduled to monitor the patient’s progress and response to treatment.
