responses.

POST 1

Natalie is a 31-year-old G0 P0 female who complains of intermittent breast pain. She thinks she feels lumps in the outer quadrants of her breasts but is unsure of the location today. She has no family or personal history of cancers, she menstruates regularly, is not pregnant, and uses condoms consistently for BCM and STI protection. 

Demographic Data 

  • 31-year-old, Female

Subjective 

  • Chef Complaint: Intermittent breast pain
  • History of Present Illness (HPI):
    • Natalie, the 31-year-old female patient (G0/P0), presented to the clinic, reporting experiencing intermittent breast pain. The patient states that she “feels lumps on the outside of her breasts,” and the pain is worse when she is closer to getting her menstrual. She also states that her breasts increase in size, and as soon as she starts her menstrual cycle, the pain subsides. The patient describes the pain as tender and sore to touch, rating it a 6/10 at its worst. She cannot identify the area where the lumps are because they come and go depending on how close to her menstrual cycle she is. She states that her periods are regular and that her period starts in 3 days. The patient takes 500mg of Tylenol for the discomfort; however, the pain goes down to a 3/10. Denies any family history of cancer.
  • Past Med. Hx (PMH):
  • Medical History: No medical history.  
  • Surgical History: Left Tibia ORIF (2010), Removal of Hardware, Left Tibia (2012).
  • Hospitalizations: No recent hospitalization
  • Medication: 500 mg Tylenol OTC for any discomfort/pain. Creatinine supplement for post-workout.
  • Cancer: No family history.  
  • Family Hx:
  • Mother: HTN, Osteoarthritis, Hyperlipidemia, alive.
  • Father: Alive, healthy.
  • Father: Social Hx:
    • Allergies: none
    • Nutrition: Good appetite, regular diet.
    • Exercise: Active 3-4 times a week.
    • Substance use: Denies current substance abuse.
    • Alcohol: Socially drinks 2-3 drinks a night when she goes out.
    • Tobacco: Vapes.
    • Occupation: CPA
    • Ethnicity: White
    • Education: Graduate Degree
    • DV/IPV: The patient states she feels safe at home.
  • Gynecological Hx:
    • G:0 P:0
    • LMP: 02/14/2024, regular, 5 days.
  • Sexually Active: Heterosexual, monogamous relationship with boyfriend. Sexually active, with condoms, no other forms of birth control.
  • Review of Systems (ROS):
    • General: No Acute Distress, denies chills and fever.
    • Cardiac: Denies chest pain and palpations. Denies swelling in feet and legs.
    • Respiratory: Denies shortness of breath.
    • Breast: Feels lumps on outer quadrants of bilateral breasts. Denies nipple discharge/skin changes/ nipple changes.
    • Genitourinary: Denies vaginal bleeding, denies vaginal odor, and denies painful intercourse. Denies vaginal itching and denies lesions.
  • Other relevant questions:

Objective 

  • Height: 5’3
  • Weight: 161 pounds
  • Blood Pressure: 122/76 mmHg
  • Temperature: 98.1 F
  • Pulse: 62 bpm
  • Respiratory Rate: 16 bpm
  • O2 Saturation: 100%
  • Pain: 3/10
  • General: Cooperative and oriented x4. Increased Blood Pressure
  • Respiratory: Good air entry bilaterally, no wheezing and no crackling. No chest wall tenderness, normal percussion. No intercoastal retraction with respirations. Patient is not coughing.
  • HEENT: PERRLA, conjunctive clear, vision grossly within normal limits. Full cervical ROM present.
  • Cardiac: No murmurs, no gallops, and normal s1/s2. No lower extremity edema.
  • Breast: The breast appears symmetrical with no visible puckering or dimpling of the skin, no visible masses or deformities, and tenderness upon palpating the outer lateral and medial borders of breast tissue; the tissue is dense to the touch; however, no lumps are present. No axillary lumps are present. Lymph nodes are nonpalpable. Nipple/areola: Symmetrical. Pink in color, everted with no dryness present or discharge. No presence of erythema.
  • Assessment (Diagnosis/ICD10 Code) 
  • ICD-10 code: N60. 0: Solitary cyst of breast.
  • ICD-10 code: N60. 3: Fibrosclerosis of breast.
  • Final Diagnosis: ICD-10 code: N64.4 – Mastodynia

Rationale: The reasoning behind the diagnosis of Mastodynia is due to the patient’s HPI, family history, and physical assessment. Cyclical mastodynia is a condition where breast pain is believed to be influenced by hormonal changes in the body, specifically fluctuations in estrogen and progesterone levels during the menstrual cycle. The pain usually occurs in the second half of the menstrual cycle and peaks just before menstruation. As the hormone levels decrease during menstruation, the pain tends to subside gradually. Cyclical mastodynia may affect both breasts and is commonly diffuse rather than localized to a specific area (Grullon & Bechmann, 2023).

Plan 

  • POCT:
    • Patient’s history and physical assessment.
  • Dx Plan
    • Given the patient’s history, an ultrasound of the bilateral breasts is sufficient; however, it is good to give the patient the option of getting a mammogram.
    • Mammogram of bilateral breasts to visualize breast tissue and density, along with the ability to identify cancers in the preferred site of pain that ultrasound cannot detect (Grullon & Bechmann, 2023).
  • Tx Plan:
  • 400 mg Ibuprofen PO every 6 hours, PRN for pain (Grullon & Bechmann, 2023). Quantity: 28. Refill: 2.
    • The reason for only 28 pills being dispensed and the discomfort is described to be experienced before getting her menstrual cycle. So I prescribed for 7 days before menstrual cycle.
  • Education:
    • Reassure the patient that she is at low risk due to her history/family history, age, and absence of concerning symptoms; however, offer imaging to get different answers.
    • Well-fitted bras help support the breast and apply compression to alleviate pain.
    • If breasts are tender, ice packs placed on the areas where the dense tissue is palpated can help alleviate pain.
    • Reduce the consumption of methylxanthines found in caffeinated beverages and food such as coffee, tea, and chocolate.
    • Increasing exercise can increase endorphins which helps with pain management.
    • Eating a low-fat diet helps reduce inflammation (Grullon & Bechmann, 2023).
    • Do not exceed more than 3200 mg of ibuprofen per day.
    • Take ibuprofen with food or a glass of milk to decrease stomach discomfort.
    • Common side effects include upset stomach, nausea, diarrhea, headache, and drowsiness.
  • How to do an efficient breast exam:
    • It is recommended to conduct self-breast exams monthly, preferably during a time of the month when the breasts are not feeling tender. To do so, stand in front of a well-lit mirror after a warm shower is breast when the skin is relaxed. Observe your breasts in the mirror and take note of any changes in size, shape, or color. Look for any dimpling, puckering, or bulging of the skin, and check if your nipples are turned in. Then, raise your arms above your head and examine your breasts for the same changes, paying attention to any alterations in contour or shape. Lie down on your back with a pillow under one shoulder and use your fingers to feel your breast tissue, moving in small circles from top to bottom and side to side. Feel for any lumps, thickening, or hardened knots, and note any new or unusual findings. Gently squeezing each nipple can help you check for any discharge. Lastly, feel your armpits for any lumps or enlarged lymph nodes. Remember, early detection is key. If you notice any changes or abnormalities, consult the provider (Henderson, et. Al. 2023)
  • Referral/Follow-up:
    • Continue to do self-breast exams and take note of any changes. If you have any concerns, please call, and make an appointment immediately. If pain increases or is intolerable, adjustments to treatment can be made.

POST 2 

Madeline is a 41-year-old female who complains of a small lump she feels in her
right breast. Upon physical examination, you palpate an approximately 2×2 cm
firm, non-tender, immobile mass in the right upper outer quadrant of the right
breast at approximately 10 o’clock, 1 cm above the areola

CC: “I feel a lump in my right breast that is finger length on the outside of my breast”.

Demographic: 41-year-old female, Asian

Subjective:

Madeline is a 41-year-old female who complains of a small lump she feels in her right breast. She reports that she noticed the lump about 5 days ago when she was in the shower and that it has not changed in size since she first felt it. She denies any pain, discharge, or changes in the color or texture of the area on her breast. Denies change of shape of the lump. She has never had a lump her breast previously. Denies recent fall or trauma to the area.

PMHx: HTN

Surgeries: Denies any Hx

Hospitalization: 2019 – pneumonia – stayed in the hospital for 3 days.

Medication – daily multivitamin OTC, 20 mg lisinopril daily p.o., denies herbal supplements. IUD was placed in 2021 on May 3rd.

Allergy- NKDA

Father: DM2, HTN

Mother: COPD, CHF

No family Hx of CA.

Social Hx: Nonsmoker, denies alcohol usage, denies illicit drug usage. Part of a softball team for recreation. Lives in a 3-bedroom apartment with her husband and 3 children. She eats out 3 days a week. Walks after dinner with her family 4 days a week.

Employment – administrative assistant

She is a G3P3.

Her last LMP was on 3/21/2024. She has regular menstruation that typically lasts 5 days with a regular flow that cycles every 27 days.

She has never had a mammogram.

ROS:

General: denies discomfort or pain. Denies weight gain or loss in the last 6 months. Denies new stressors in life.

HEENT:  Denies sore throat, difficulty swallowing, dizziness, vision changes,

hearing changes, neck tenderness, and headache.

Respiratory: Denies SOB and wheezing.

Cardiovascular: Denies chest pain or palpitations.

GI – Denies Bowel changes, stomach pain, nausea, and vomiting.

Gu- Denies painful urination, denies vaginal discharge.

Breast: denies pain, tenderness, or discharge. Reports nodule in the right breast.

Pap Smear- 6/19/2023 – negative.

Objective

VS: BP: 108/72, HR 98, RR:18, TEMP 97.6, O2 SAT: 97% HT: 5 feet 5 inches WT: 128.9 lbs.

BMI: 21.4

General: Well-groomed, in no acute distress.

HEENT: PERRLA. Ears, nose, and throat without obstruction or exudate assessed.

Cardiovascular: s1 and s2 heard. No rubs, murmurs, or gallops are present.

Respiratory: Breathing even and unlabored. Clear auscultation bilaterally.

Gastrointestinal: soft, nondistended. Normoactive bowel sounds in all quadrants.

Psychiatric: normal mood and affect.

Breast – palpation of golf ball-sized nodule noted at 10 o’clock of the right breast 1 cm above the areola. Immobile mass. No erythema was noted. No axillary lesions were noted. No dimpling was noted. Smooth, firm, regular border. 

Skin- Warm, dry, and intact.

Assessment:

D 24 – Fibroadenoma – round 2 cm x 2cm mass. Non-painful. Golf-ball – regular smooth border.

Differential

N60.01 – Breast Cyst – the patient has a firm mass and is immobile.

Breast Tumor- the mass does not have irregular borders. No discharge, nonpainful, no dimpling.

Plan: Mammogram of the breast to assess for breast cancer – breast abnormalities, if needed an ultrasound can be done if breast tissue results as dense. Tumor marker blood draw. A fine needle aspiration biopsy of the area can be done of the mass on the right breast to confirm fibroadenoma versus cancerous result. “Overall, screening mammograms miss about 20% of breast cancers that are present at the time of screening. False-negative results can lead to delays in treatment and a false sense of security for affected women” (National Cancer Institute, 2023, Paragraph 8).

Treatment: Monitor the lump for changes in shape, painfulness, discharge, tenderness, and skin condition changes such as redness or texture. If the biopsy returns with cancer results, the patient will be contacted for a new treatment plan.

Educate: Perform regular breast self-exams. Annual breast mammograms- 41, recommend mammogram starting at age 40 and screened every 2 years. Regular exercise – at least 30 minutes a day for 5 days a week. Eat a well-balanced diet and get adequate hydration with 2.5 L of water a day. Encourage to wear a sports bra while playing sports and at night when sleeping. Fibroadenoma is a noncancerous mass in the breast tissue.

Follow up – return in 6 months to reassess mass and repeat imaging. Call the office for any new lumps or change of current lump with the monitoring conditions mentioned previously.

Health maintenance: Currently up to date with all pertinent vaccines. 

Reference

National Cancer Institute. (2023). Mammograms. National Cancer Institute. 

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