NSG 6430 Week 4 Discussion PDF

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NSG 6430 WEEK 4 DISCUSSION iHuman Case Study – Rachael Hardy iHuman Case Study – Rachael Hardy Rachel Hardy is a 42-year-old woman presenting with a chief complaint of two right breast lumps that are constant and began 6 months ago. She reports a biopsy three years ago, which was negative for cancer. Rachel reports that her mother had breast cancer when she was 48 years old. 

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Discuss the questions that would be important to include when interviewing a patient with this issue. According to Goolsby & Grubbs (2015), the nurse practitioner (NP) should utilize the PQRST (palliative/provoking, quality, radiation, severity, timing) sequence when gathering a history related to a breast complaint. Additionally, it is critical for the NP to obtain the patients medical history, family history and social history to determine their risk factors for breast cancer (Goolsby & Grubbs, 2015). Have you gained or lost weight unintentionally despite normal appetite and exercise? Do you have any pain, swelling, or redness in your breasts? Any change in the appearance or position of your nipple? Do you have skin dimpling or retraction on your breasts? Have your breasts changed in size or tender? Do you have any discharge? Where is the breast lump located and is the lump in your breast moveable? Do you have any swollen lymph nodes? When did the problems with your breast start and are they associated with your period? Have you ever had breast problems like this before? Any fever, fatigue or tiredness? Do you drink alcohol or smoke? Does anyone in your family have breast problems or a history of breast cancer? Tell me about your current or past medical problems, current prescription and over the counter medications. Have you ever taken hormonal replacement therapy or are you using any form of birth control?

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Describe the clinical findings that may be present in a patient with this issue. The clinical presentation of breast cancer includes asymmetry of breasts, lymph node enlargement, a fixed, firm and painless mass (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017). Additional assessment findings include nipple discharge or skin/nipple changes such as dimpling (peau d’orange appearance and nipple retraction) (Goolsby & Grubbs, 2015). Late assessment findings include fatigue, weight loss, and anorexia (Buttaro et al., 2017).

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Are there any diagnostic studies that should be ordered on patient? Why? Mammography to evaluate breast tissue (Buttaro et al., 2017) Ultrasound to differentiate fluid filled cyst from a solid mass (Buttaro et al., 2017) Biopsy to determine malignancy depending on radiologic/imaging studies and clinical suspicion (Buttaro et al., 2017) BRCA 1 and BRCA 2 screening to determine if Rachel has mutation in this gene which would increase her risk for breast cancer (Hawkins, Roberto-Nicholas, & Stanley-Haney, 2016).

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List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each. Breast mass/lump, neoplastic (Primary DX): Rachel’s breast biopsy was positive for invasive ductal carcinoma and her lymph-node biopsy was also positive for metastatic breast adenocarcinoma. Differential diagnosis includes  Fibroadenoma: This commonly presents as a painless, firm mass that is a benign lesion (Goolsby & Grubbs, 2015).  Fibrocystic Breast Disease: Characterized as a spectrum of breast tissue changes including cysts and lobular hyperplasia that presents with smooth, movable masses on assessment (Goolsby & Grubbs, 2015).  Phyllodes tumors (malignant or benign): According to the American Cancer Society (2019), these are common in women in their 40’s such as Rachel and present as a painless breast lump. 

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Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.  Nonpharmacological management: Mastectomy or surgical excision

 Pharmacological therapies: Chemotherapy and/or Radiation  Tests: Genetic Testing (BRCA), baseline bone scan, CT of abdomen and chest (Goolsby & Grubbs, 2015).  Referrals: Breast surgeon/specialist and oncologist (Buttaro et al., 2017).  Patient Education: Breast cancer follow up includes education on yearly/regular gynecological follow up, surveillance screening with a clinical breast exam every 6-12 months, mammogram and/or MRI every 612 months (Buttaro et al., 2017). References American Cancer Society. (2019). Phyllodes Tumors of the Breast. Retrieved from https://www.cancer.org/cancer/breast-cancer/non-cancerous-breastconditions/phyllodes-tumors-of-the-breast.html. Buttaro, T., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary Care: A Collaborative Practice (5th ed.). St. Louis, MO: Elsevier. Goolsby, M. J., & Grubbs, L. (2015). Advanced assessment: Interpreting findings and formulating differential diagnoses (3rd ed.). Philadelphia, PA: F.A. Davis Company. Hawkins, J., Roberto-Nicholas, D. & Stanley-Haney, J. (2016). Guidelines for Nurse Practitioners in Gynecologic Settings (11th ed.). New York, NY: Springer Publishing. Schuiling, K. D. & Likis, F. E. (2016). Women's gynecologic health (3rd ed.). Sudbury, MA: Jones & Bartlett....