NRNP 6552 Common Gynecologic Conditions Assignment Discussion

NRNP 6552 Common Gynecologic Conditions Assignment Discussion

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Patient Initials: J.M.

Age: 49 years

Gender: Female

SUBJECTIVE DATA

Chief Complaint (CC): I have a lump in my left breast.

History of Present Illness (HPI): Mrs J.M., a 49-year-old gravid woman, complains of a left breast lump. She reports that she first felt it three months ago, but she could not make an appointment due to her work schedule. She also states that it is non-tender and mobile and has increased in size. No skin discolouration was reported, however.

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Current Medications

• PO pregnacare one tab OD.
• PO 250mg B.D.

Allergies

No known allergies.

Past Medical History

Known hypertensive for five years. She complies with her medications, and the pressures have been well controlled.

Social and Substance History

She is married with two living children. The patient denies a history of cigarette smoking or recreational/ illicit substance abuse. She has a positive history of alcohol consumption during social gatherings. She reports taking evening walks at least 4-5 times a week and is on a low-fat diet NRNP 6552 Common Gynecologic Conditions Assignment Discussion.

Family History

She is the 2^nd born in a family of 4. All siblings are alive and well. The mother is alive and known hypertensive. The father died secondary to a road traffic accident.

Maternal grandmother is alive, living with Parkinson’s.

Maternal grandfather is deceased due to an unknown illness.

Paternal grandmother is deceased due to CVA.

Paternal grandfather is alive and diabetic.

 Surgical History

She has no history of surgery.

Mental History

She denies having anxiety or depression. She has no history of self-harm or suicidal ideations.

Violence History

She expresses no concerns about her security.

Reproductive History

Gynecologic

She attained menarche at 15 years old. Her cycle is regular after 21 days and lasts 3-5 days. Uses three tampons per day, fully soaked. She denies intermenstrual bleeding. She has a history of use of oral contraceptives and implants previously.

Obstetric history

She gravida three has had two full-term pregnancies, one abortion, and two living kids.

Review of Systems:

General: No history of weight changes, chills, fever and night sweats.

HEENT: Head: Denies head trauma. Eyes: No history of visual disturbances, eye pain or discharge. Ear: Denies difficulty hearing, pain, tinnitus and vertigo. Nose: No history of nose bleeds, nasal congestion and pain. Throat: Denies voice hoarseness and sore throat.

Respiratory: No history of difficulty breathing, hemoptysis or chest pain.

Cardiovascular: Denies palpitations, orthopnea and dyspnea.

Gastrointestinal: No history of acid reflux, abdominal pain and constipation.

Genitourinary: No history of dysuria, increased urgency and frequency.

Musculoskeletal: Denies muscle pain/weakness, joint pain or swelling.

Neurological: No history of numbness or tingling, dizziness or loss of consciousness.

Skin: No wounds or sores on the skin. Denies abnormal skin discolouration.

Allergies

No history of eczema, asthma or hay fever.

OBJECTIVE DATA

Physical Exam:

Vital signs: T= 98.2ºF, RR=18breaths/minute, non-labored, HR=66 regular, BP=126/80 left arm, Oxygen Saturation=98% on room air; Wt=135 lbs., Ht= 5’5’’, BMI= 22.5

General: Mrs J.M is in a fair general condition, seated comfortably and is not in distress.

HEENT: Head: No noticeable swelling or signs of trauma. Eyes: The conjunctiva is pink and moist, has no corneal ulceration and has normal visual acuity. Ears: No congenital anomaly of the outer ear, the tympanic membrane is shiny and grey, and hearing is intact bilaterally.

Neck: Supple, no jugular venous distension, the thyroid gland is located in the mid-line and is not enlarged. No lymph node enlargement.

Respiratory: There is no difficulty breathing. The chest is clear with no added sounds, and expansion is equal bilaterally.

Breast: Both breasts are symmetrical are there is no skin colour changes. The left breast has a non-tender cystic mass measuring 3cm in the upper outer quadrant.

Cardiovascular: The apex beat is not displaced, and the precordium is normoactive. S1 and S2 are heard and regular. No gallops, rubs or murmurs.

Abdomen: Linea Alba was visualized. Palpable mass at 20 weeks gestation.

Genital/Rectal: Patient declined.

Musculoskeletal: No gross abnormalities noted. No joint stiffness, pain or swelling. Normal range of movement.

Neurological: She is alert and oriented *3. Able to follow simple and complex commands. Cranial nerves are grossly intact. Has normal motor and sensory function.

Skin: No abnormal discolouration, wounds or rashes noted.

Diagnostic Results

Mammography: Screening tool used in early detection of breast cancer.

Core Needle Biopsy: Obtain a sample of the tissue to evaluate the type of mass further.

ASSESSMENT

Fibroadenoma (N60.22): A marble-like mass consisting of stromal and epithelial tissues underneath the breast’s skin. Research studies show that the most common cause is hormonal in origin, which relates to increased sensitivity of breast tissue due to estrogen. According to Gupta et al. (2019)NRNP 6552 Common Gynecologic Conditions Assignment Discussion, fibro adenomas mostly grow during pregnancy and shrink during menopause. It mainly presents as a solitary, mobile, non-tender, rubbery consistency and rapidly growing solid lump with regular borders. Also, it is mainly located in the upper outer quadrant of the breast. Since Mrs J.M. is gravid and has a lump in the upper outer quadrant that is non-tender, this increases the likelihood of the diagnosis.

Lipoma (D17.1): A benign tumour of the adipocytes that can be located in any part of the body. Researchers have linked trauma to lipoma formation. They mainly present as painless, solitary, soft subcutaneous nodules that are mobile and not associated with epidermal changes (Balsarkar et al., 2021). They often portray a characteristic slippage sign elicited by gently sliding the fingers off the edge of the tumour. More examination findings should have been provided in Mrs J.M’s case to make a more definitive diagnosis of lipoma.

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Breast cancer (C50.452): According to Watkins, (2019), it is the most commonly diagnosed cancer in women. The risk factors are classified as modifiable and non-modifiable. Modifiable risk factors are obesity, smoking and exogenous hormone use, whereas non-modifiable include advanced age, previous history of breast cancer, family history, gender, early menarche nulliparity and late menopause. Majority of patients present with a painless lump that is immobile. The advanced disease presents with oedema of the skin (peau d’orange)NRNP 6552 Common Gynecologic Conditions Assignment Discussion, fixation to the chest wall and frank ulceration. A comprehensive history and further investigation are required to rule out the diagnosis.

Plan

Fibroadenoma

• Reassure the patient. According to Gupta et al. (2019), fibro adenomas shrink and disappear with time. However, surgical intervention is indicated if it progressively increases in size and compresses other breast tissues.
• Refer for surgical review.

Lipoma

• Since it is asymptomatic, advise on watchful wait and monitor the progress.
• Refer for surgical review.

Breast cancer

• Requires a multi-disciplinary team as the mother is gravid. Therefore management would plan to refer to the obstetrics and surgical team.

Reflection

One agrees with the diagnosis of fibroadenoma from the patients presenting complaints and examination findings. However, a comprehensive history and physical examination are required to rule out other diagnoses.

Women should be educated on lifestyle changes since obesity is a major modifiable risk factor. Advise them to engage in physical activities and have healthy dietary habits.

 Additional Questions

Ask about a positive history of breast cancer in the family. Studies have shown that approximately 13-19% of patients diagnosed with breast cancer have a first-degree relative affected by the same condition (Watkins, 2019)NRNP 6552 Common Gynecologic Conditions Assignment Discussion. Inquire if there are associated symptoms such as axillary lymphadenopathy or nipple discharge.

References

Balsarkar, D. J., Suryawanshi, S. A., Shaikh, M., & Dhobale, S. (2021). Giant lipoma of breast-a diagnostic dilemma. International Surgery Journal, 8(2), 752. https://doi.org/10.18203/2349-2902.isj20210398

Gupta, A., Zhang, H., & Huang, J. (2019). The Recent Research and Care of Benign Breast Fibroadenoma: Review Article. Yangtze Medicine, 03(02), 135–141. https://doi.org/10.4236/ym.2019.32013

Watkins, E. J. (2019). Overview of breast cancer. Journal of the American Academy of Physician Assistants, 32(10), 1. https://doi.org/10.1097/01.jaa.0000580524.95733.3d

Episodic/Focused SOAP Note Template

 Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.”

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American female). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example: NRNP 6552 Common Gynecologic Conditions Assignment Discussion

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better NRNP 6552 Common Gynecologic Conditions Assignment Discussion

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.

PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.

Soc & Substance Hx: Include occupation and major hobbies, family status, vaping, tobacco and alcohol use (previous and current use, how many times a day, how many years), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.

Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx: Prior surgical procedures.

Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical)NRNP 6552 Common Gynecologic Conditions Assignment Discussion.

Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns.

ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS: NRNP 6552 Common Gynecologic Conditions Assignment Discussion

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

GENITOURINARY/REPRODUCTIVE: Burning on urination. Pregnancy. LMP: MM/DD/YYYY. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?. sexually active?

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:)NRNP 6552 Common Gynecologic Conditions Assignment Discussion.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

A.

Primay and Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?

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Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).

References

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. NRNP 6552 Common Gynecologic Conditions Assignment Discussion