2023 1 Please reply to the following discussion with one reference Participate in the discussion by

1) Please reply to the following discussion with one reference. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite resources in your responses to other classmates.

2) Also, answer the following question in a separate small paragraph with one reference.

Question: She tells you she uses topical progesterone, does this make a difference?

Discussion

Discuss the questions that would be important to include when interviewing a patient with this issue, including any risk factors she may have.

Some of the questions that the clinician may ask the patient will include the following: At what age did the patient begin menarche? How long has the mass been present? Do you have a history of breast lumps? Did the lump change in size with your menstrual cycle? How long has it been since your last menses? Is there any discharge coming from the nipple? Did you experience recent weight loss? Did you take any hormone replacement therapy (HRT)? Did you have any trauma to the breast? Have you had a mammogram or breast biopsies and when and what were the results?  Do you have a family history of breast cancer?  Do you have any diagnosis of breast cancer (Hawkins, Roberto-Nichols, & Stanley-Haney, 2016)?

 Describe the clinical findings that may be present in a patient with this issue. Are there any diagnostic studies that should be ordered on this patient? Why?

The patient with the diagnosis will breast cancer may not experience any symptoms in the initial stages of the development of the disease. Indicators that dictate the progression of the disease includes the following symptoms that the person experiences such as a change in the size, shape, or skin changes of the breast, color, skin dimpling, nipple inversion, nipple abnormalities, discharge, and axillary lump (Koo, Wagner, Abel, McPhail, & Rubin, 2017). To detect a difference in the breast, tissue the patient must be examined upright with arms raised, hands pressed against hips, and leaning forward. The axillae and the supraclavicular sites should be assessed when examining the breast tissue. The best technique to use detect a mass when palpating the breast is the vertical strip pattern (Bickley, 2017). The diagnosis of breast cancer is determined through diagnostic mammography and breast biopsy. The use of the diagnostic mammogram assists the clinician in determining the presence of a benign or malignant tumor in woman older than 40 years old. A breast tissue biopsy is used to obtain a large tissue sample of a mass to be examined to determine the presence of cancerous cells in the breast tissue (Koo et al., 2017)

 List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each.

The primary diagnosis:

Breast cancer- The diagnostic test revealed that the patient has breast cancer (invasive ductal carcinoma estrogen-receptor positive progesterone-receptor positive) the diagnosis is distinctive due to the risk factor of the patient’s previous history of atypical hyperplasia of the breast. The diagnosis of atypical hyperplasia of the breast is considered a high-risk breast mass that predisposes the patient to breast cancer. Additionally, the patient has a first-degree relation that was diagnosed with breast cancer. The breast biopsy results solidify the diagnosis of breast cancer (Hartmann, Degnim, Santen, Dupont, & Ghosh, 2015).

Differential diagnoses:

Fibrocystic Disease- The diagnosis for fibrocystic breast disease is a possibility for the patient as she presents with the clinical manifestation of possibly asymptomatic singular or multiple palpable smooth breast mass or a mobile round lump. The fibrocystic breast commonly occurs between the age of 30-50 years of age. The breast changes affiliated with fibrocystic disease comprises of atypical ductal and epithelial hyperplasia (Malherbe & Fatima, 2021). However, this is not the diagnosis as the mass does not change with the onset of the patient’s menses.

Fibroadenomas- The diagnosis of fibroadenomas as they are glandular fibrous tissue that occur during the reproductive year which may be associated with hormone production (Williams, 2018). A risk factor related to fibroadenoma is a familial history of breast disease. The mass is typically a benign painless mobile mass. The diagnosis is of fibroadenoma as the lesion does not fluctuate with the presence of the patient’s menses.

Breast Lipoma- The differential diagnosis of a breast lipoma is possible they can be benign or cancerous as they are the most common soft tissue tumor. A breast lipoma is a unilateral, smooth, soft, painless mass that occur between the ages of 40 to 60 years of age. The diagnosis is not apparent as the pathologic interpretation of the breast biopsy indicates that the patient has breast cancer cancer (Domino, Baldor, Golding, & Stephens, 2017)

Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.

The course of treatment for the patient would involve a consult with the oncologist to direct and guide the course of treatment. The oncologist may prescribe Tamoxifen 20 mg twice a day as the form of cancer that the patient has is hormonal estrogen-receptor positive (Hartman et al., 2015). The patient may also have a lumpectomy of the right breast to remove the disease. A follow-up with radiation therapy to ensure eradication of the disease Hartman et al., 2015).  She will have a mammogram six to twelve month after radiation. A mammogram one year after that.  An annual gynecologic examination. The patient is instructed to not have blood pressure taken on the right arm due to lymphedema. The patient is instructed to observe for new lumps, pain (in bone, chest, stomach), shortness of breath, and headaches.

References

Bickley, L. S. (2017). Bates’ guide to physical examination and history taking (12th ed.). [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9781496354709/cfi/372!/4/[email protected]

Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B. (2017). The five-minute clinical consult 2018 (26th ed.). Philadelphia, PA: Wolter Kluwer Health/Lippincott Williams & Wilkins

Hartmann, L. C., Degnim, A. C., Santen, R. J., Dupont, W. D., & Ghosh, K. (2015). Atypical hyperplasia of the breast-Risk assessment and management options. New England Journal of Medicine, 372(78).  Retrieved from https://www.nejm.org/doi/pdf/10.1056/NEJMsr1407164

Hawkins, J. W., Roberto-Nichols, D. M., & Stanley-Haney, J. L. (2016). Guidelines for nurse practitioners in gynecologic settings (11th ed.). New York, NY: Springer Publishing Company

Malherbe, K. & Fatima, S. (2021).  Fibrocystic breast disease.  StatPearls.  Retrieved from https://ncbi.nlm.nih.gov/books/NBK551609/

Williams, J. (2018).  Education case: Fibroadenoma of the breast.  Academic Pathology. https://doi.org/10.1177/2374289518790926