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Case Scenario 1
Table 1
In your own words include what type of screening (clinical breast exam, self breast exam, screening mammogram) is needed depending on the age and risk factor of the patient.
ACOG ACS USPSTF
Women under age 40
Women aged 40-49 years
Women aged 50-74 years
Women aged 75 years and older
Women with dense breasts
As you can see each organization has different screening guidelines, it is best to follow the protocols in your clinic for more guidance. Keep these guidelines in mind when answering the case scenario.
Table 2
The American College of Radiology Breast Imagine Reporting and Data Systems (BI-RADS)
Definition
BI-RADS 0
BI-RADS 1
BI-RADS 2
BI-RADS 3
BI-RADS 4
BI-RADS 5
BI-RADS 6
Madeline is a 41-year-old female who complains of a small lump she feels in her right breast. Upon physical examination, you palpate an approximately 2×2 cm firm, non-tender, immobile mass in the right upper outer quadrant of the right breast at approximately 10 o’clock, 1 cm above the areola.
Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.

  1. Subjective:
    a. What other relevant questions should you ask regarding the HPI?
    b. What other medical history questions should you ask?
    c. What other social history questions should you ask?
    d. What other family history questions should you ask?
  2. Objective:
    a. Write a detailed focused physical assessment on this patient.
    b. Explain what test(s) you will order and perform, and discuss your rationale for ordering and performing each test.
  3. Assessment/ Diagnosis:
    a. What is your presumptive diagnosis? Why?
    b. Any other diagnosis or differential diagnosis you would like to add?
  4. Plan:
    a. What are your next steps and plan of care for this patient? Explain your rationale
    b. Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s),
    c. What patient education is important to include for this patient? (Consider including pharmacological, supplements, and non pharmacological recommendations and education)
    d. What is the follow-up plan of care?
    e. Explain complications that can occur if patient does not comply with treatment regimen.
    Please refer to evidence-based guidelines to support your decision-making.
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Sample Answer

 

 

 

 

Case Scenario: Madeline, 41-year-old with Breast Lump

Subjective

HPI: 41-year-old female presents with a palpable lump in the right breast. The lump is approximately 2×2 cm, firm, non-tender, and immobile, located in the right upper outer quadrant at the 10 o’clock position.

PMH:

  • Hypertension
  • Hyperlipidemia

SH:

  • Smokes 1 pack per day
  • Drinks alcohol occasionally
  • Sedentary lifestyle

FH:

  • Mother had breast cancer at age 55

Objective

Physical Exam:

  • Breast Exam: Right breast: 2×2 cm firm, non-tender, immobile mass in the upper outer quadrant. Left breast: No palpable masses or abnormalities.
  • Axillary Lymph Nodes: No palpable lymph nodes.

Full Answer Section

 

 

 

 

Diagnostic Tests:

  • Mammogram: To assess breast tissue density and identify any abnormalities.
  • Breast Ultrasound: To further characterize the breast mass and differentiate between solid and cystic lesions.
  • Biopsy: To obtain tissue for histopathological examination and confirm the diagnosis.

Assessment/Diagnosis

Presumptive Diagnosis: Breast mass, likely malignant.

Differential Diagnosis:

  • Fibroadenoma
  • Cyst

Plan

Next Steps:

  • Schedule a mammogram and breast ultrasound.
  • Refer the patient to a breast surgeon for biopsy.

Treatment Guidelines and Side Effects:

  • Surgery: Surgical excision of the tumor, possibly with axillary lymph node dissection, depending on the biopsy results.
  • Chemotherapy: May be recommended based on tumor characteristics and stage. Common side effects include hair loss, nausea, and fatigue.
  • Hormone Therapy: May be used to block estrogen and progesterone, which can fuel tumor growth. Side effects may include hot flashes, night sweats, and vaginal dryness.
  • Radiation Therapy: May be used to kill any remaining cancer cells after surgery. Side effects can include skin irritation, fatigue, and increased risk of secondary cancers.

Patient Education:

  • Importance of regular breast self-exams and mammograms.
  • Risk factors for breast cancer and preventive measures.
  • Side effects of treatment and how to manage them.
  • Importance of follow-up care.

Follow-up Plan:

  • Schedule a follow-up appointment with the breast surgeon to discuss the biopsy results and treatment plan.
  • Monitor for any signs of recurrence or metastasis.

Complications of Non-Compliance:

  • Disease Progression: Delayed diagnosis and treatment can lead to more advanced disease and poorer prognosis.
  • Metastasis: Cancer can spread to other parts of the body, such as the lungs, liver, or bones.
  • Increased Morbidity and Mortality: Non-compliance can increase the risk of complications and death.

It is crucial to provide clear and compassionate patient education, address any concerns or questions, and ensure that the patient understands the importance of adhering to the treatment plan.

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