Case Study For Patient Complaining Of Nipple Discharge Assignment

Case Study For Patient Complaining Of Nipple Discharge Assignment

Patient information                                                                                                                                                                                                    Patient initials: M.L    Age: 28y/o    Gender: female             Race: Hispanic

S:

CC: “Nipple drainage.”

HPI: M. L, a 28-year-old Hispanic female, presented to the clinic unaccompanied with a chief complaint of nipple discharge that had begun three months ago. The patient characterizes the discharge as milky in color and reports general fatigue and constipation lately. She also claimed that her monthly cycle has been relatively light, and she is concerned that she may have cancer. She has not yet sought treatment. Denies having a fever, dizziness, or stomachache. Case Study For Patient Complaining Of Nipple Discharge Assignment

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Medication; She is currently not on any medication.

Allergy: NKDFA

PMH:

GYN: 12-year-old menarche. Menstruation is regular and lasts for four days. Denies using any contraceptive. No history of STIs or vaginitis. LMP 12/7/22. G2P2.

Immunization: up to date. She received her last mammogram on 4/2/2022 and a tetanus shot on 5/9/2021

PSH: none

Family history: Father (65-y/o): hypertension and diabetes type 2. Mother (deceased): breast cancer. Maternal grandfather (87-y/o): hypertension. Maternal grandmother (78-y/o): Bipolar disorder. Elder sister (60-y/o): COPD. Younger brother: no known medical condition.

Psychiatric Hx: no past mental history was reported, but the patient admitted to anxiety over her current medical condition.

SHx: M.L is a mother of two. She is a teacher at a nearby elementary school. She has a very supportive husband who works full-time as a lecturer in a nearby college. She is financially stable, and her life is covered by insurance. She lives with her family in their apartment. She denies ever smoking a cigarette but admitted to drinking alcohol once in a while with her husband. She also reported attending gymnastics every weekend for exercise. The patient reported wearing a safety belt and never using her phone while driving. She eats a healthy diet full of fruits and vegetables. Case Study For Patient Complaining Of Nipple Discharge Assignment

ROS

General: Denies fevers, chills, and weight changes. Reported having fatigue

HEENT: negative for cataract, retinopathy, and visual defects. Negative for hearing problems. Denies running nose, nosebleed, any dental pain, and sore throat.

Cardiovascular: Denies chest pain, heart murmur or galops, edema, and paroxysmal nocturnal dyspnea

Respiratory: Denies SOB, cough, wheezing, and emphysema

GI: denies a decrease in appetite and nausea. Denies heartburn, vomiting, or diarrhea. She reported constipating lately.

Msk: negative for back pain, arthritis, and joint deformity

Neurologic: Denies dizziness, syncope, headache, seizures, and blackout.

Genitourinary: denies incontinence, abnormal vaginal discharge, breast lumps, and yeast infection. She reported a three-month nipple discharge.

Psychiatric: Denies insomnia, homicidal ideation, and depression.

Skin: negative for rashes or acne.

Endocrine: negative for thyroid issue, heat or cold intolerances.

Vascular: harmful for atherosclerosis or leg ulcers.

O.

PE

VTS: BP 120/68 left arm, sitting using a regular adult cuff. Wt.: 165lb Ht.: 5’4 T.: 37.1 RR: 18 P: 7 6 Sp02: 98%

General: A&Ox3 appear mildly distressed by her current medication

HEENT; normocephalic and atraumatic. EOMI intact, PERRLA, fundi appear normal.

Cardiovascular: RRR, S1, S2 head. Neither murmur nor gallops

MSK:  Full range of motion noted in all joints. Muscle strength is 5’s bilaterally. Capillary refill >3 sec. Case Study For Patient Complaining Of Nipple Discharge Assignment

Skin:  Intact without rashes.

Abdomen: Soft and non-tender. Bowel sounds are present and normoactive.

Genital: external genitalia are normal in appearance. The vagina is pink. Cervix non-tender, and uterus anteflexed. Ovaries are non-tender without palpable masses.

Breast: soft, with no masses noted. Tender. Nipples are symmetrical and milky discharge was evident.

Neuro: the sensation is intact. Memory and thought processes are intact.

Psychiatric: Oriented to place and time. Good insight and judgment.

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Assessment:

Diagnostic test and result

HCG test:  positive for pregnancy

Breast ultrasound: negative for malignancy

Differential Diagnoses

  • Pregnancy

Pregnancy prompts several changes in women’s body, including breast changes. One of the most common breast changes during pregnancy is nipple discharge. This can be due to an increase in the level of estrogen in the body and preeclampsia (Tang et al.,2019)Case Study For Patient Complaining Of Nipple Discharge Assignment . Pregnancy is also characterized by fatigue and the urge to constipate, which was evident in the case scenario. Following the HCG lab test and patient report of having had a light menstrual cycle which would have been a sign of implantation, this is the most likely diagnosis for the patient.

  • Pituitary adenomas

Pituitary adenomas are a type of brain tumor that can lead to several symptoms, including nipple discharge. This discharge is caused by the adenoma pressing on the pituitary gland, which affects the body’s production of hormones. This can lead to several problems, including infertility and breast cancer (Beck-Peccoz et al.,2019). The light bleeding menstrual cycle is also typical in cases where adenoma is malignant; it is also characterized by headaches, seizures, and vision changes that were not evident in the case presentation.

  • Vaginal fibroids

Vaginal fibroids are benign tumors that develop in the vaginal wall. Fibroids range from 1-2 mm to 3-4 cm. They can appear individually or in groups. Fibroids can form on the vaginal wall, in the muscular wall, or in the uterine lining (womb). The typical signs of vaginal fibroids are creamy nipple discharge and mild bleeding (Stewart et al.,2020)Case Study For Patient Complaining Of Nipple Discharge Assignment . These symptoms might be minor or severe, and their severity can change over time. Pelvic discomfort, difficulties getting pregnant, and a change in the shape or size of the uterus are all possible indications and symptoms of fibroids. This might be a plausible diagnosis; however, no tumor or abnormalities in uterine shape were seen during the physical examination.

Primary diagnoses: pregnancy

Plan

Lab test: OB blood test is recommended.

Medication: give prenatal vitamin one tab PO QD throughout pregnancy.

Patient education: the patient should be encouraged to avoid taking as it can complicate her pregnancy. She should be advised to have enough rest and eat healthy food with plenty of fluids. She must be assured that the discharge is normal, is not related to cancer, and would stop within no time. She must teach the importance of observing proper hygiene during pregnancy. She must be told other changes she might experience, which are also expected during pregnancy.

Follow-up: The patient should report back to the clinic after four weeks for further assessment.

Referral: to the gynecologist in case of complication.

 

Reflection

Nipple discharge is a relatively common condition that affects women of all ages. It can result from hormonal changes during pregnancy, breastfeeding, pituitary adenoma, and vaginal fibroids, and it is not always a sign of breast cancer. Proper diagnoses are necessary to rule out the more probable cause of the disorder to curb unnecessary complications. Besides, the patient must be thoroughly counseled to better understand their condition and plan of care. In cases where pregnancy is ruled out as the root cause of the symptoms, another test such as an OB blood test is necessary to rule out any infection that may complicate the pregnancy. The patient must also be put on prenatal vitamins for at least three months to prevent complications for both mother and fetus Case Study For Patient Complaining Of Nipple Discharge Assignment .

Part B: case study questions

Question 1:

There are three types of nipple discharge: physiologic, pathologic, and galactorrhea. Physiologic discharge occurs with stimulation and is typically clear or white. Pathologic discharge occurs with or without stimulus and is characterized by a change in color or consistency. Galactorrhea is a type of pathologic discharge that is due to milk production and is characterized by a thick, yellowish discharge. Based on the case scenario, the patient nipple discharge fits into physiological discharge.

Question 2

Besides nipple discharge and other concerns noted, the patient might be experiencing increased urination, nausea with or without vomiting, and breast tenderness.

Question 3

Women with a more robust genetic history of the breast are candidates for BRCA1 and two genetic testing for mutation.

Quetion4

  1. Examination of the breast based on its characteristics, such as asymmetry and characteristics of the discharge
  2. The four most important exams for the client would include taking her family history to rule out any genetic links to her condition. Her medication history determines whether the current drug may contribute to her condition. Then mental status examination to rule out her insight and judgment concerning deciding on a healthy lifestyle. Physical assessment of her entire body to establish other significant signs and symptoms Case Study For Patient Complaining Of Nipple Discharge Assignment .

Question 5

There are many potential causes of nipple discharge, but some of the most common include medications (such as birth control pills or antipsychotic drugs, phenothiazine, and H2 blockers), hormonal imbalances, and pregnancy.

Question 6

The nipple discharge should be tested for abnormal cells, bacteria, and fungi. Additionally, a biopsy may be performed to rule out the possibility of breast cancer. If the discharge is bloody or contains pus, cultures should be performed to determine the cause. A pregnancy test may be performed if the discharge is clear or white.

Question 7

Cytologic studies are not recommended for nipple discharge testing because they cannot accurately diagnose the cause of nipple discharge. In addition, cytological studies cannot determine whether the nipple discharge is due to a benign or malignant condition. Finally, cytological studies cannot determine whether the nipple discharge is due to a duct al or lobular lesion Case Study For Patient Complaining Of Nipple Discharge Assignment .

Question 8

Yes! If there are palpable masses

Question 9

Other than mammograms, other tests applicable include CT scans and MRI. This test is key in establishing the presence of a tumor of pituitary tumor, which may be the root cause of the discharge.

Question 10

Lab test: A blood test and pregnancy test

Question 11

  1. MRI indicated that the level of prolactin and TSH level is high.
  2. The three differential diagnoses: are pregnancy, pituitary adenoma, and vaginal fibroids.

Question 12:

If galactorrhea is suspected due to a chemical origin, the person should stop taking the suspected medication. If it persists, the person may need to be treated with a dopamine agonist.

Question 13

There is no definitive answer to this question as both premenopausal and postmenopausal women can experience galactorrhea. However, some studies have suggested that galactorrhea is more common in premenopausal women. This may be since premenopausal women have higher estrogen levels, stimulating milk production.

Question 14

There is no standard approach to the workup of nipple discharge. One possible approach would be to refer all patients for surgical evaluation. An alternate method would be to obtain a complete history, perform a thorough physical examination, and obtain a detailed mammogram.

Question 16

Breastfeeding and be advised that the galactorrhea will resolve with the cessation of breastfeeding

Question 17

Nipple discharge is often a sign of breast cancer, so it concerns most women Case Study For Patient Complaining Of Nipple Discharge Assignment .

References

Stewart, E. A., Lukes, A. S., Venturella, R., Li, Y., Hunsche, E., & Al-Hendy, A. (2020). Relugolix Combination Therapy Reduced Uterine Fibroid-Associated Pain in Two Phase 3 Liberty Studies. Journal of Minimally Invasive Gynecology, 27(7), S8.

Beck-Peccoz, P., Giavoli, C., & Lania, A. (2019). A 2019 update on TSH-secreting pituitary adenomas. Journal of endocrinological investigation, 42(12), 1401-1406.

Tang, R., Kelly, B. N., Smith, B. L., Lanahan, C. R., Brown, C. L., Gadd, M. A., … & Coopey, S. B. (2019). Nipple discharge after nipple-sparing mastectomy with and without associated pregnancy. Clinical Breast Cancer, 19(4), e534-e539 Case Study For Patient Complaining Of Nipple Discharge Assignment .

Please follow the directions below regarding the the soap note. template uploaded. please answer all the questions.

Here is the case study for the week 9 SOAP note. Please be sure you clearly indicate where the answers to the questions are located. You can either incorporate into SOAP note in bold or highlighted, or you can answer them at the end of the note.

Please write this assignment like a regular SOAP note you would write in actual clinical practice (with pertinent positives and negatives ). Some students are writing the note in a hypothetical way with questions they would ask the patient.

Case study
Marcia is a 28-year-old female who comes in with a complaint of nipple drainage. She says that the discharge started about three months ago and it appears milky. She says that she has also felt tired, and has been constipated lately. Her periods have been very light. She is worried that she “might have cancer.”

Questions

1 What are the three classifications of nipple discharge? What classification does this fit into?

2 Aside from the above concerns, name three other things this woman may be experiencing.

3 Women with a strong family history of breast cancer may be candidates for genetic testing for __________ mutations.

4 You do a thorough breast examination on this pt. What are two important components of this exam on anyone with nipple drainage?
You do a complete medication history as well as elicit past medical history, including endocrine and reproductive history. What are four important parts of the exam on this pt and why?Case Study For Patient Complaining Of Nipple Discharge Assignment

5 Name five chemical agents that can cause nipple discharge and galactorrhea.

6 What should the nipple discharge be tested for?

7 Why are cytologic studies not recommended?

8 Should diagnostic mammography be performed?

9 Following diagnostic mammography, what other imaging study might be performed and why?

10 What are two important lab tests to obtain?

11 When would an MRI of the brain be indicated?
Name three possible diagnoses for this patient.

12 If galactorrhea is suspected due as a result of a chemical origin, what must be done?

13 Is galactorrhea more common in premenopausal or postmenopausal women?

14 Should all patients with spontaneous or unilateral nipple discharge regardless of color, be referred for surgical evaluation?
Patients should be educated that most causes of breast discharge are malignant.

16 In women with galactorrhea, where the prolactin level is normal and menses are normal, women should be informed of the normal physiologic association with ______________________.

17 Why is nipple discharge so concerning to most women?

Rubric Detail

A rubric lists grading criteria that instructors use to evaluate student work. Your instructor linked a rubric to this item and made it available to you. Select Grid View or List View to change the rubric’s layout.

Content
Name: NRNP_6565_Week9_Assignment_Rubric
Grid View
List View
Excellent
90%–100% Good
80%–89% Fair
70%–79% Poor
0%–69%
Create documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned.

In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Current medications
• Allergies
• Patient medical history (PMHx)
• Review of systems
Points Range:9 (9.00%) – 10 (10.00%)
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.
Points Range:8 (8.00%) – 8 (8.00%) Case Study For Patient Complaining Of Nipple Discharge Assignment
The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.
Points Range:7 (7.00%) – 7 (7.00%)
The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but it is somewhat vague or contains minor innacuracies.
Points Range:0 (0.00%) – 6 (6.00%)
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing.
In the Objective section, provide:
• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
Points Range:9 (9.00%) – 10 (10.00%)
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
Points Range:8 (8.00%) – 8 (8.00%)
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.
Points Range:7 (7.00%) – 7 (7.00%)
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.
Points Range:0 (0.00%) – 6 (6.00%)
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.

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In the Assessment section, provide:
• At least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.
Points Range:23 (23.00%) – 25 (25.00%) Case Study For Patient Complaining Of Nipple Discharge Assignment
The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the conditions selected.
Points Range:20 (20.00%) – 22 (22.00%)
The response lists in order of priority at least three different possible conditions for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the conditions selected.
Points Range:18 (18.00%) – 19 (19.00%)
The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.
Points Range:0 (0.00%) – 17 (17.00%)
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
In the Plan section, provide:
• A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits.
• A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.
• Reflections on the case describing insights or lessons learned.
Points Range:27 (27.00%) – 30 (30.00%)
The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas. Case Study For Patient Complaining Of Nipple Discharge Assignment
Points Range:24 (24.00%) – 26 (26.00%)
The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. An accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate critical thinking.
Points Range:21 (21.00%) – 23 (23.00%)
The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies. Reflections on the case demonstrate adequate understanding of course topics.
Points Range:0 (0.00%) – 20 (20.00%)
The response does not address all diagnoses or is missing elements of the treatment plan. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. Reflections on the case are vague or missing.
Provide 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 they are current (no more than 5 years old) and support the treatment plan in following current standards of care.
Points Range:9 (9.00%) – 10 (10.00%)
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.
Points Range:8 (8.00%) – 8 (8.00%)
The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions.
Points Range:7 (7.00%) – 7 (7.00%)
Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan.
Points Range:0 (0.00%) – 6 (6.00%)
Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence based or do not support the treatment plan.
Written Expression and Formatting – Paragraph Development and Organization: Case Study For Patient Complaining Of Nipple Discharge Assignment
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
Points Range:5 (5.00%) – 5 (5.00%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
Points Range:4 (4.00%) – 4 (4.00%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.

Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
Points Range:3 (3.00%) – 3 (3.00%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.

Purpose, introduction, and conclusion of the assignment are vague or off topic.
Points Range:0 (0.00%) – 2 (2.00%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time.

No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English Writing Standards:
Correct grammar, mechanics, and proper punctuation
Points Range:5 (5.00%) – 5 (5.00%) Case Study For Patient Complaining Of Nipple Discharge Assignment
Uses correct grammar, spelling, and punctuation with no errors.
Points Range:4 (4.00%) – 4 (4.00%)
Contains 1 or 2 grammar, spelling, and punctuation errors.
Points Range:3 (3.00%) – 3 (3.00%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
Points Range:0 (0.00%) – 2 (2.00%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/narrative in-text citations, and reference list.
Points Range:5 (5.00%) – 5 (5.00%)
Uses correct APA format with no errors.
Points Range:4 (4.00%) – 4 (4.00%)
Contains 1 or 2 APA format errors.
Points Range:3 (3.00%) – 3 (3.00%)
Contains several (3 or 4) APA format errors.
Points Range:0 (0.00%) – 2 (2.00%)
Contains many (≥ 5) APA format errors.
Name:NRNP_6565_Week9_Assignment_Rubric Case Study For Patient Complaining Of Nipple Discharge Assignment