Subjective: ID: JC 46 year old female Source: Patient is the historian CC: Patient states “I found a lump in my left breast” HPI: 46 year-old female present to clinic today for a lump in left breast that is not painful. Has Patient noted the lump on the left lateral breast 9 months ago, since than has increased in size. JC denies performing self breast exams and mammograms. Patient states “ I know it is not cancer because I’m so young and healthy and if it is I’d rather die than cut my breast off “ JC started her menses at 11 and has a regular 27 day cycle. Her LMP was 2 weeks ago, JC is G0P0. O: JC notice lump 9 months ago L: Left breast D: Present symptoms for 9 months C: PT reports feeling a painless hard lump A: Symptoms are stable R Lump grew in size T: Patient is not receiving and treatment currently PMH: Allergies: NKDA, food, environmental, or latex allergies Chronic Illness: NONE Hospitalization NONE Surgeries: NONE Family History: Mother and sister both had mastectomies in their 40’s elated to breast Cancer. Brother has no medical illnesses, father has a history of HTN. JC is single. Social History: JC denies drinking ETOH, tobacco, street drugs, or prescription drug use She lives alone in an apartment and immediate and extended family lives nearby. JC is a project manager at and local advertising agency and has adequate health insurance, JC religion is Catholic. Violence HX: Patient denies any domestic abuse ROS: General: Patient denies any weight lost, fatigue, fever. Skin: Denies rashes, bruising, skin discoloration, lesion or moles Eye: Denies vision problems Ear: Denies any pain in the ears, lost of hearing, dizziness or sensitivity to noise Mouth/Throat:Denies any sore throat, change in voice, dental problems or eating difficulties Breast: Palpated 1 cm hard lump in the upper outer quadrant of left breast Cardio:Denies any chest pain, arrythmiais, palpations, HTN, edema Resp: Denies any cough, wheezing, hemoptysis, dyspnea, or TB history Gyne/U: Denies any vaginal d/c, JC is sexual active, use condoms and spermicide for Birth control, yearly Pap smears, denies any itching or burning. Patient also Denies burning, pain, or urgency when urinating GI: Denies abd pain, N/V/D, constipation, or black tarry stools MS: Denies back pain, swelling in the joints, or osteoporosis Neuro: Denies any seizure, weakness, paresthesias, syncope,paralysis out blackouts Heme/Lymph:HIV negative, denies bruising, blood transfusion, increase thirst/hunger, cold or heat intolerance Psychiatric: Denies any mental health illiness, sleeping difficulties, or suicidal attemps, patient Also denies family hx of mental illness OBJECTIVE V/S BP 114/62 P 82 R 16 TEMP 37.1 WT 148 BMI 24.0 Physical Examination General: Patient appearance is clean alert and oriented in obvious distress. HEENT: Eyes: PERRLA, EOM intact. Significant scleral icterus.Ears: canals patient No nasal d/c, septal deformity, Nasal mucosa pink MMM. Oropharynx clear with no lesions/erythema Neck: Supple with no LAD or masses. Lymph Nodes: No cervical or inguinal LAD. Cardiovascular: RRR. Prominent heart sounds, S1 and S2 normal, no m/g/r. Pulses 2+ equal on both sides. Lungs: No crackles/rhonchi/wheezes. Bilateral clear lung sounds. Skin: dry, clean, intact, no bruises, rashes, or lesions Psychiatry: Alert and oriented to person, place, and time, appropriate, and polite manner Abdomen: Normoactive bowel sounds, soft and nondistended, NT, ND. Liver palpable 1-2 cm below costal margin. spleen palpated. No rebound or guarding. Extremities: No bilateral cyanosis, clubbing or edema. No petechiae. Capillary refill <3 sec. MSK: No pain, swelling, or deformities. No erythema. Neurological: Cranial nerves II-XII grossly intact, normal sensation throughout, normal cerebellar function. DTR 2+ symmetrical. PELVIC: deferred Rectal: deferred Lab Test: CBC, LP, CMP, D-dimer, PT, PTT Special Test: Mammogram, breast ultrasound, fine needle aspiration biopsy Assessment: BREAST: REVEALS BREAST EQUAL, MEDIUM SIZE AND SYMMETRY, EVEN PIGMENTATION, AND NO DISCOLORATION LEFT BREAST NIPPLE IS SLIGHTLY RETRACTED. SIGNIFICANT DIMPLING NOTED ON THE LEFT BREAST BREAST UPPER OUTER QUADRANT 1 O'CLOCK SEEN WHEN PATIENT AREM ARE RAISED OVER HER HEAD. PALPATION OF THE BREAST INCLUDED NO LUMPS OR MASSES FOUND IN THE RIGHT BREAST. LEFT BREAST NIPPLE 2CM IMMOVABLE, NONTENDER, AND FIRM NODULE WITH SMALL AMOUNTS OF CLEAR, BLOODY DISCHARGE WITH SQUEEZED, LYMPH NODES IN BOTH AXILLA ARE NOT PALPATED. Diagnosis 1 Breast cysts may be found in one or both breasts. Signs and symptoms of a breast cyst include: A smooth, easily movable round or oval lump that may have smooth edges which typically, though not always, indicates it's benign. Nipple discharge that may be clear, yellow, straw colored or dark brown. Complex cysts contain cystic and solid components and are associated with a variety of benign, atypical, and malignant pathologic diagnoses. Complex cystic breast masses have a substantial chance of being malignant; malignancy was reported in 23% (,1) and 31% (,2) of cases in two series. Diagnosis 2 In situ carcinoma is "pre-invasive" carcinoma that has not yet invaded the breast tissue. These in situ cancer cells grow inside of the pre-existing normal lobules or ducts. In situ carcinoma has significant potential to become invasive cancer, and that is why it must be adequately treated to prevent the patient from developing invasive cancer. Invasive cancers have cancer cells that infiltrate outside of the normal breast lobules and ducts to grow into the breast connective tissue. Invasive carcinomas have the potential to spread to other sites of the body, such as lymph nodes or other organs, in the form of metastases. Approximately 80% of breast carcinomas are invasive ductal carcinoma, followed by invasive lobular carcinomas which account for approximately 10-15% of cases. Invasive ductal carcinomas and invasive lobular carcinomas have distinct pathologic features. Specifically, lobular carcinomas grow as single cells arranged individually, in single file, or in sheets, and they have different molecular and genetic aberrations that distinguish them from ductal carcinomas. Ductal and lobular carcinomas may have different prognoses and treatment options, depending upon all of the other features of the particular cancer. The remaining cases of invasive carcinoma are comprised of other special types of breast cancer that are characterized by unique pathologic findings. These special types include colloid (mucinous), medullary, micropapillary, papillary, and tubular. It is important to distinguish between these various subtypes, because they can have different prognoses and treatment implications. Final Diagnosis Malignant neoplasm of the left breast, which develops when erratic cell growth and proliferation occur in the breast tissue. The lesion is usually hard, painless and irregular borders, that are immovable. In later stages, axillary, cervical, and supraclavicular lymph node are commonly associated with breast cancer. Plan: Educate JC on Radiology testing that is needed for staging and treatment her breast cancer, such as MRI, biopsy, labs such as estrogen, progesterone and HCG receptors. Plan to initiated early referrals to breast oncology, and nutritionist. Obtain finance department to decrease worry about her financial obligation. Educated patient on mental health related to her diagnosis, and teach patient how to examine the other breast for tumors or discoloration. Submit a referral to the breast cancer agency, such as AVON, or Y-ME. Arrange for testing to be done ASAP so spreading will be decrease. Educate patient on the need for yearly mammograms and checking breast 1 week after her menstrual cycle, and family genetics related to her diagnosis. References Centers for Disease Control and Prevention. (2019, June 10). Genetic testing for hereditary breast and ovarian cancer. Centers for Disease Control and Prevention. Retrieved February 19, 2022, from https://www.cdc.gov/genomics/disease/breast_ovarian_cancer/testing.htm Cedars-Sinai Medical Center. (2019, October 25). New recommendations for BRCA testing: Should you be screened? Retrieved February 19, 2022, from https://www.cedarssinai.org/newsroom/new-federal-guidelines-for-brca-testing-should-you-be-screened/ Cathy R. Kessenich is a professor of nursing and MSN program director at University of Tampa. (n.d.). Genetic testing for BRCA1 and BRCA2 genes : The nurse practitioner. LWW. Retrieved February 18, 2022, from https://journals.lww.com/tnpj/Citation/2014/06000/Genetic_testing_for_BRCA1_and_B RCA2_genes.2.aspx
