Breast Conditions
A 25-year-old woman presents for evaluation of right-sided breast pain. She reports the onset suddenly 7 days ago. She has never been pregnant, her menses occur monthly, and she is using combined oral contraceptive pills as her method of contraception. She denies significant medical and surgical history, no change in weight, and has no first degree or family relatives with breast cancer, either maternally or paternally. Her Pap smear 2 years ago was normal, and she is sexually active with one male partner. Her last menstrual period was 3 weeks ago and today is day 22 of her cycle. She denies trauma to the chest area, has no nipple piercings, and no significant breast stimulation during sexual activity. She does not practice monthly breast exams and her last clinical breast exam was 2 years ago. She drinks socially approximately 2 alcoholic beverages per week and does not smoke or use illicit substances.
Using the Master of Science in Nursing Clinical Note format
- What portion of the physical exam is of most concern for the APRN?
- Provide three differential diagnoses based on the case presented.
- Please list the plan/intervention for management for this condition.
Master of Science in Nursing Clinical Note
Patient Information:
- Age: 25-year-old female
- Chief Complaint: Right-sided breast pain
History:
- Menstrual history: Monthly periods; currently using combined oral contraceptive pills
- Pregnancy history: Nulligravida
- Medical/surgical history: No significant medical or surgical history
- Family history: No family history of breast cancer
- Pap smear: Normal 2 years ago
- Sexual history: Sexually active with one male partner
- Menstrual cycle: Day 22 of the cycle
- Breast examination: No regular breast exams; last clinical breast exam 2 years ago
- Lifestyle: Social alcohol consumption (approximately 2 drinks per week); non-smoker
- What portion of the physical exam is of most concern for the APRN? The breast examination is of most concern for the APRN, given the patient’s presentation of right-sided breast pain. A thorough breast examination is essential to assess for any abnormalities, such as lumps, masses, or other signs that may indicate the cause of the pain.
- Provide three differential diagnoses based on the case presented: a. Musculoskeletal Pain: Consider musculoskeletal causes for the breast pain, such as muscle strain or injury, which can mimic breast pain. b. Mastitis: Infection or inflammation of the breast tissue, which can cause localized breast pain, redness, and warmth. While less common in non-lactating women, it can still occur. c. Fibrocystic Breast Changes: This condition can cause breast pain and tenderness and is more common in young, premenopausal women. It involves the development of non-cancerous lumps or cysts in the breast tissue.
- Plan/Intervention for Management: a. Physical Examination: Conduct a thorough clinical breast examination to assess for any palpable lumps, masses, or signs of infection (e.g., redness, warmth). b. Imaging: Consider a diagnostic mammogram or breast ultrasound to further evaluate any abnormalities found during the examination. c. Laboratory Tests: Perform a complete blood count (CBC) and inflammatory markers if mastitis is suspected to rule out infection. d. Pain Management: Prescribe over-the-counter pain relievers and recommend warm compresses for pain relief if musculoskeletal or breast pain due to fibrocystic changes is suspected. e. Patient Education: Educate the patient about the importance of regular breast self-exams, given her young age and risk factors. Encourage her to practice monthly breast self-examinations and offer guidance on how to do so. Emphasize the importance of follow-up care based on examination and test results.
The patient should be closely monitored, and a follow-up appointment should be scheduled to review the examination and test results, ensuring that the cause of her breast pain is accurately diagnosed and managed. If any abnormalities are found, they will need to be further investigated and managed accordingly.