Physical Examination and Health Assessment
- Please respond to the discussion prompt. Week 5 :
Select one of the following case studies to address:
- A 49-year old man reports feeling fullness in his right armpit and nipple discharge at his right areola . He denies other symptoms, significant medical history, or allergies.
- A 31-year old Black woman reports her breasts get swollen, hard, and lumpy at times and she has pain that comes and goes. She has heard that Black women have a high rate of breast cancer.
- A 27-year old woman complains of multiple small tender lumps in her right and left axillae. She explains that she has noticed that they seem to make “tunnels” and sometimes open and smell bad.
For the case you have chosen, post to the discussion:
- Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
- In SOAP format, list:
- Pertinent positive and negative information
- Differential and working diagnosis
- Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
- Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
- In your peer replies, please reply to at least one peer who chose a different case study.
Chief Complaints– â€œBreast got swollen, hard and lumpy at time, with on and off painâ€
History of Present Illness-A 31- year old Black woman reported swelling of her breast, hard and lumpy at times, experienced intermittent pain. She is concerned and worried higher chances of breast cancer with black people.
An acronym often used to organize HPI, termed OLDCARTS
Do you perform regular monthly breast self exam?
Onset: When did symptom begin?
Location: Where is the lump and swelling located?
Duration: How long is lump, swelling and pin bee going for?
Characterization: How would you describe the pain or lump?
Alleviating or Aggravating factors? What makes the pain worse or better?
Radiation: Does the pain move from one location?
Temporal factor: Is the pain worse of better at a certain time of the day?
Severity: How would you rate the pain using pain scale, 10 being the worst and 1 being the least?
PAST MEDICAL HX:
- Any childhood diseases? Any past medical condition such as hypertension, diabetes, asthma, UTI, kidney problems, or cancer?
Pertinent Positive Findings: palpable mass in one breast, pain may be cyclic or noncyclic. Symptoms typically arise on the 3rd of 4th decades of life. Cyclic discomfort usually appears a few days before menstruation and disappears quickly. In most people, the pain is described as persistent and mild, however it can sometimes be pulsating and create a burning feeling. During their reproductive years, over 80% of women will have at least one episode of nipple discharge. Approximately 5% to 10% of women who come in for a regular checkup will have spontaneous nipple discharge (Epocrates, n.d.).
Pertinent negative finding: no axillary or lymph node involvement, no bloody nipple discharge. No puckering or dimpling noted.
- Surgical History: Try to include the recent surgery and the surgeon if possible
- Family History: Anyone in the family has cancer, hypertension, diabetes, asthma, or copd?
- Social History: An acronym that may be used here is HEADSS which stands for Home and Environment; Education, Employment, Eating; Activities; Drugs; Sexuality; and Suicide/Depression.
- Questions include, what type of current home, apartment, house, board and care, who does she live with, nature of work, any hobbies. Is she a smoker or with hx of smoking use of illicit drugs. Any history of depression or suicide attempts.
- Age of Menarche, is she on hormone therapy?
- Currents Medications: Is she on oral contraceptives, which can be a risk factor for breast mass. Include the name, dose and frequency of the medication
- Allergies: Drugs, food and environment and their reactions
- Immunizations: Are you up to date on vaccines?
Review of Symptoms:
General: any fever, or weakness, weight loss or decreased in appetite
Head: any lumps in the head or pain
Eyes: Any discharge or burning sensation? Any change in vision recently
Nose: any nose bleeding
Throat: Any pain when swallowing?
Respiratory: Any Sob, cough
Cardiovascular: Any chest pain, palpitations, swelling to upper and lower extremities?
Gastrointenstinal: Any abd pain ,nausea/vomiting or diarrhea
Genitourinary: Any dysuria or blood in the urine
Musculoskeletal: Any pain or decrease of range of motion
Lymphatics: Any nodules noticed in the neck or axillary region
Urogenital: Are you sexually active? Are you in a heterogenous or homo relationship?
Vitals, BMI, General appearance of the patient and Review of Systems obtained by the clinician.
General Appearance: Patient is alert and oriented, not in apparent distress, well-nourished and is dressed appropriately. She is the primary source of information. Speech is clear and coherent and she maintains eye contact throughout the interview.
Integumentary: Assess for ABCDE, Asymmetry, border irregularity, color variation, diameter of the lump, elevation of the lump
Head: Inspect for lumps, and symmetry of the head
Eyes: Assess for PERRLA, discharge, erythema
Nose: Assess if there is drainage or erythema
Throat: Assess the tonsils if there is enlargement
Respiratory: Assess for wheezing, rhonchi
Chest/Breast: Assess for tenderness, rash, discharge
Cardiovascular: Assess for rate, rhythm, edema to upper and lower extremities, cap refill
Gastrointestinal: Assess for bowel sounds, abdominal tenderness
Genitourinary: Assess for blood in the urine
ASSESSMENT and PLAN:
- Working Diagnosis: Fibrocystic breast- breasts that are “lumpy” and have soreness and discomfort that change with the menstrual cycle. Excluding other serious breast illnesses is a common part of the diagnosis process. Risk assessment for the development of breast cancer is crucial and may be used to reassure patients or create risk reduction methods.
- Chest Wall Pain- The pain in the chest wall is persistent and noncyclic. It’s possible that it’s linked to physical exercise. On examination, the discomfort is produced by delicately moving the breast tissue against the chest wall.
- Costochondritis- Pain above the costochondral cartilaginous junction on the anteromedial portion of the chest wall.
- Breast Cancer- A palpable lump, generally firm upon palpation, may be present. Breast cancer should be suspected if there is skin retraction or attachment to the chest wall.
Diagnostic tests, Medications, Patient Education and Follow-up Care
- Mammograpy and Breast Ultrasound- Patients with a history of a persistent breast mass, suspicion of a mass on breast inspection, or suspicious nipple discharge should have diagnostic mammography and breast ultrasonography performed.
- Breast Biopsy- is used to distinguish between fibrocystic breasts and cancer when imaging investigations reveal solid lumps. An intraductal papilloma (70 percent), breast cancer (5 percent), or ductal ectasia are the most common causes of suspicious nipple discharge (25%).
MEDICATIONS and PATIENT EDUCATION:
- Reassurance: Patient worry can be alleviated by reassuring them about the consequences of monthly hormonal cycles and estrogen effects. Women think that wearing a bra that offers adequate support is beneficial. Some women appear to have less pain when they limit their caffeine or salt intake, although this has not been scientifically proven.
- Teach and encourage patient to perform breast self exam regularly.
- Modification of therapeutic regimens in postmenopausal women using hormone replacement therapy (HRT) is a viable strategy, considering that reported rates of HRT-induced breast discomfort vary for various combinations and preparations compared to placebo.
- Acetaminophen: 325mg-1000mg every 4-6 hours interval, max dose up to 4000mg/day
- Ibuprofen: 400mg-800mg every 4-6 hours interval, maximum dose of 3200mg/day
- Primary option-Tamoxifen: 10mg oral dose daily on days 1-25 of menstrual cycle for 3 months. Tamoxifen is a competitive inhibitor of estrogen, acting as an estrogen agonist/antagonist.
- Secondary option-Bromocriptine: 1.25mg once po daily at bedtime initial dose, increase by 1.25mg/day increments over 2 weeks ,usual dose is 2.5mg twice daily- a prolactin inhibitor.
- Tertiary option- Danazol- 100mg oral, 2x a day as initial dose, starting on day 2 of menstrual cycle, decrease to 100mg daily on day 2 of cycle after 2 months, then decrease to 100mg once daily on days 14-28 cycle or 100mg on alternate days of amenorrheic. Danazol suppresses gonadotropins, resulting in androgenic, antiestrogenic, and antiprogestogenic activity.
PROCEDURES and RECOMMENDATIONS:
- Cyst Aspiration- In most individuals with a palpable cyst, aspiration is done, especially if the cyst is symptomatic (painful) or if the specific diagnosis from the look on ultrasonography is unclear (and aspiration is therefore for diagnostic purposes). If an ultrasound reveals that a breast tumor is a simple cyst, the American Society of Breast Surgeons recommends that it not be drained unless it is bothersome.
- If the nipple discharge in non supiscious with no breast mass present- reassure patient and observe.
- If the nipple discharge is nonsuspicious and breast mass present- refer to oncologist- Patients who have a nipple discharge and a palpable accompanying tumor or mammographic abnormalities should see an oncologist as soon as possible.
- If the nipple discharge in suspicious- When a worrisome nipple discharge is discovered, even if no palpable lump is present and mammography is normal, a specialist visit is required. If the discharge is bloody and excessive, a microductectomy (removal of a single problematic milk duct) or a central duct excision may be required.
Clinical presentation and symptoms: depending on the intensity and influence of symptoms on the patient’s lifestyle, individuals with recurring or chronic pain or breast cysts may require follow-up at 3- to 6-month intervals. After cyst aspiration, a brief interval follow-up examination is recommended to check for cyst recurrence (which may be linked to the existence of intracystic papilloma or cancer).
PROMPT 2 JASMIN
Case Study #2
- Chief Complaint: A 31-year-old African-American female presents today with â€œbreasts get swollen, hard, and lumpy at times and she has pain that comes and goes.â€
- History of Present Illness: The patient reports intermittent pain and swollen, hard, lumpy breasts.
- Questions to ask: When did the episodes begin? Is it isolated to the breast region only or the axillae or chest? Did it begin unilaterally or bilaterally? Can she describe the pain? Is there a specific time or activity that makes the pain worse? Has she tried anything at home to relieve the pain? Is the pain worse before her menstrual cycle? How often do her breasts become swollen?
- Medical History: No information given.
- Questions to ask: Any current medical conditions? Any past childhood illnesses? Has she ever been pregnant? Has she ever given birth? Has she delivered a baby recently? Any previous history of breast surgery?
- Social History: No information given.
- Questions to ask: Does she smoke or drink alcohol? Was she playing any contact sports, rigorous running, or weightlifting when the symptoms first began?
- Family History: No information given.
- Questions to ask: Any history of breast cancer or other conditions?
- Preventive Care: No information given.
- Questions to ask: When was her last physical exam? When was her last clinical breast exam? When was her last visit to the OB/GYN? Has she ever had a mammogram performed? Does she perform self-breast examinations? If so, when was the last one performed?
- Allergies: No information given.
- Questions to ask: Does she have any allergies to medications? Does she have any environmental allergies?
- Medications: No information given.
- Questions to ask: Does he take any medications? Any contraceptives? Did she recently start new medications? Does she take over-the-counter medications? Has she taken any new supplements?
- Review of Systems:
- General: Any recent fever, fatigue, malaise, or unexplained weight loss?
- Skin: Has the skin on her breasts become thicker or thinner?
- Breast: Any recent trauma to the breast area? Any nipple discharge? Any hard masses within the breasts? Is she currently breastfeeding?
- Respiratory: Any recent wheezing or shortness of breath that accompanied the other symptoms? Any chest pain on inspiration or expiration?
- Cardiovascular: Any recent heart palpitations or chest pain alongside the breast pain?
- Reproductive: Are her menstrual cycles regular? When was her last menstrual cycle? Do the symptoms begin before her menstrual cycle begins?
- Functional: Is the breast pain constricting movement throughout her daily life?
- General: Vital signs need to be obtained to determine if the patient is febrile (which can correlate as a positive pertinent finding for non-lactating mastitis).
- Integumentary: Inspect and palpate the skin from the clavicular area down to the upper abdomen. If she has noticeable skin changes with lesions, they should be documented for asymmetry, border irregularity, color variation, diameter, and elevation should be noted (Jarvis, 2015). For breast tissue, the breast mass, retraction, edema, axillary mass, scaly nipple, and tenderness should be noted (Daines et al., 2015).
- Breast: A bilateral breast exam should be performed. Inspect the breast for any skin changes, bruising, discoloration, erythema, nipple retraction, dimpling, or obvious asymmetry (Daines et al., 2015). Palpate the entire breast area, including the chest wall and axillary areas. Document masses by size, breast, location, mobility, quadrant, and distance from the midline.
- Pertinent positive findings: Multiple mobile, round, and tender nodules can indicate fibrocystic changes. Non-tender, mobile, and round nodules can indicate fibroadenomas.
- Pertinent negative findings: Nontender and hard masses will require further study to rule out malignancy. Nipple discharge that is bloody can also indicate malignancy rather than hormonally-induced changes (Fenstermacher & Hudson, 2020).
- Respiratory: Auscultate lungs, anterior and posteriorly, to rule out wheezing and crackles. Palpate intercostal margins for tenderness and pain.
- Pertinent negative finding: Rules out a respiratory compromise or inflammatory conditions.
- Cardiovascular: Auscultate for any murmurs, gallops, or bruits.
- Pertinent negative finding: Abnormalities can provide evidence to rule out a working diagnosis.
- Lymphatic: Inspect and palpate supraclavicular, infraclavicular, and axillary lymph nodes for lymphadenopathy.
- Pertinent positive findings: Swelling of the axillary nodes can correlate to localized infection, such as mastitis (Fenstermacher & Hudson, 2020).
- Working Diagnosis:
- Fibrocystic Breast Disease: The patient reports intermittent lumpy, hard, and painful breasts (pertinent positive findings).
- This mastalgia condition presents with lumpy breasts with smooth, well-defined, mobile nodules of varying sizes and shapes that are either consistent or cyclic (Fenstermacher & Hudson, 2020). Tenderness on palpation in breasts unilaterally or bilaterally 1-2 weeks before the menstrual cycle and resolves 2 weeks after the cycle ends. Pain is worse before menstruation and described as sore or heavy before spontaneously resolving after the cycle (Daines et al., 2015). They occur most often in women ages 30 to 50, correlating to the patient.
- Differential Diagnosis:
- Nonlactating Mastitis: The patient reports intermittent lumpy, hard, and painful breasts (pertinent positive findings). Pain is bilateral (pertinent negative finding).
- This condition presents with sharp or burning breast pain in one breast in a localized area. Nipple retraction, enlarged and painful axillary lymph nodes, erythema of affected site on breast, and a palpable tender breast mass will be detected (Fenstermacher & Hudson, 2020). Fever may be present in this condition.
- Inflammatory Breast Cancer: The patient reports lumpy, hard, and painful breasts (pertinent positive findings). Symptoms are intermittent and both breasts affected (pertinent negative findings).
- This condition appears similarly to acute mastitis, but differs in that most of the entire breast is swollen, mass shape irregular, fever is rarely present, and axillary lymphadenopathy can be present (Daines et al., 2015).
- Fibroadenoma: Patient reports lumpy and hard breasts (pertinent positive findings). The patient reports bilateral breasts affected intermittently with pain (pertinent negative findings).
- This condition presents with a firm, smooth, well-defined, and hard mass that is painless (Jarvis, 2015). Fibroadenomas vary in size, can enlarge or shrink on their own, and affect only one breast,
- Laboratory workup:
- Complete blood count (CBC): can correlate to infectious etiology (Daines et al., 2015).
- Ultrasound: Helpful in differentiating solid from cystic lesions if the patient presents with masses (Daines et al., 2015).
- Mammogram: In the presence of a palpable mass or nipple discharge, a diagnostic mammogram is necessary to identify palpable lumps or abnormal screening mammograms (Daines et al., 2015). Women over 30 should be screened with a mammogram and ultrasound when abnormalities are detected in the breast tissue (Cornell et al., 2020).
- Fine-needle aspiration biopsy: This can be performed if suspicious masses are present on palpation (Fenstermacher & Hudson, 2020).
- Ibuprofen 600mg PO every 6 hours as needed for pain (Cornell et al., 2020).
- Patient education:
- Patient education on behavioral modifications such as cessation of caffeine, tea, chocolate, alcohol, and nicotine. Stress management also important if symptoms are aggravated with emotional distress.
- Educated on incorporating foods rich in Vitamin E and B6 to reduce symptoms such as nuts (especially peanuts), fish (such as salmon and trout), and dark leafy green vegetables (Cornell et al., 2020).
- Instructed to use cold or hot compresses to the breast when pain occurs. Circular massages over breast tissue and hot showers can relieve discomfort.
- Educated on wearing a well-fitted good support bra instead of loose-fitting or no bra (Fenstermacher & Hudson, 2020).
- Demonstrated through teach-back and educated patient on performing a self-breast examination monthly a week after her menstrual cycle.
- Patient educated on the use of medication for pain control, informed of side effects, adverse effects with alcohol, and to take with food.
- Written education was given to the patient regarding normal and malignant changes of breast tissue across the lifespan for preventive cancer education. According to statistics from the Centers for Disease Control and Prevention (CDC), white women have the highest rates for breast cancer at 125.8 cases per 100,000 patients with black women coming in second at 121.3 (CDC, 2017).
- If sudden shortness of breath and chest pain occurs at home, the patient was informed to seek emergency care.
- The patient was instructed to follow up in a month if diagnostic results are normal.