Exam (elaborations) NR 602 DISCUSSION WEEK 4 PBL CASE STUDY DISCUSSION WOMEN'S HEALTH PART ONE (GRADED)

Exam (elaborations) NR 602 DISCUSSION WEEK 4 PBL CASE STUDY DISCUSSION WOMEN'S HEALTH PART ONE (GRADED) PBL Case Study Discussion: Women's Health Part One (graded) Overview: Kayla, a now 38-year-old Caucasian and Latino female, comes in the month after Riley’s last illness complaining of fatigue, right breast pain, and vaginal itching. HPI: The breast pain began in the right breast and is now into the right axilla. It is warm and tender to touch. She has not noticed any nipple discharge. She has also had mild myalgia. The vaginal itching began a few days before the breast pain. She reports a great deal of stress. She has not been monitoring for a fever. She denies diarrhea or constipation, abdominal pain, skin changes, cough, or chest pain. She has not had dysuria. LNMP was 6 weeks ago, 8 days in length, heavy for 5 days with clots. This was her first menses since her last visit with you. Menses are irregular, having only 5 to 6 per year. PMH: As previously given. Social History: She continues to live with her parents during a separation from her husband and is working part time at the children’s school library but has not been there for over a week. She now has no health insurance, but her children are covered by the State Medicaid HMO. Family History: Her paternal great grandmother died of breast cancer at the age of 50. Otherwise her family history has not had updates or changed since her last visit. Discussion Questions Part One What further historical questions are needed to properly care for her? What are your differential diagnoses? What is your rationale for these diagnoses? K.F., 38yo, F, Caucasian and Latino S. CC- fatigue, right breast pain, vaginal itching HPI- The breast pain is in the right breast and now into the right axilla. It is warm and tender to touch. She has not noticed any nipple discharge. She has also had mild myalgia. The vaginal itching began a few days before the breast pain. She reports a great deal of stress. She has not been monitoring for a fever. She denies diarrhea or constipation, abdominal pain, skin changes, cough, or chest pain. She has not been sleeping well, due to having to stay with her daughter in the hospital. No recent physical or well woman exam since the birth of her son. She has not had dysuria. LNMP was 6 weeks ago, 8 days in length, heavy for 5 days with clots. Menses are irregular, having only 5 to 6 per year. PMH- No surgical history other than cesarean sections; no trauma history; 10 year 1PPD smoker, smoking cessation 2 years ago; gestational diabetes with last pregnancy; history of PCOS. This study source was downloaded by from CourseH on :57:27 GMT -05:00 This study resource was shared via CourseH NR 602 DISCUSSION WEEK 4 PBL CASE STUDY DISCUSSION WOMEN'S HEALTH PART ONE (GRADED) Social History- She continues to live with her parents during a separation from her husband and is working part time at the children’s school library but has not been there for over a week. She has no health insurance, but her children are now covered by the State Medicaid HMO. Family History- Her paternal great grandmother died of breast cancer at the age of 50. Her mother has hypertension, hyperlipidemia, and type 2 diabetes. Her father has hypertension, hyperlipidemia, and cardiovascular disease. What further historical questions are needed? Breast Pain: O- When did the breast pain start? Was there any trauma or event that started the pain? L- Exactly where is the pain at, point at it with one finger? D- Is the pain constant or intermittent? C- What are the characteristics of the pain? (Sore, achy, pin prick, stabbing) A- Is there anything that makes the pain worse? R- Is there anything that makes the pain better? T- Have you tried any treatments for the pain and discomfort? S- What is your pain on a scale of 1-10? Have you ever had a mammogram? If so what were the results? Family history of breast or ovarian cancer? Do you drink a lot of caffeine or fatty foods? Vaginal Itching: O- When did the vaginal itching start? L- Where exactly is the itching located? D- Is it constant or intermittent? C- Is there any vaginal discharge or odor? Color, smell? A- Does anything make the itching worse? R- Does anything make the itching better? T- Have you tried any treatments for the itching? S- What is the severity of the itching? When is the last time you had sex? Do you have multiple sexual partners? Have you ever had a STD? Is there a chance you can be pregnant? When did the fatigue and myalgia start? This study source was downloaded by from CourseH on :57:27 GMT -05:00 This study resource was shared via CourseH Have you felt you may have been feverish? When was your last pelvic exam with Pap smear? Where the results normal? What are your differential diagnosis with rational? Mastodynia (N64.4) - Breast pain is usually associated with a benign breast condition; it is rarely a sign of breast cancer. Pain may be felt in one or both breasts, or just in part of one breast. Pain may also be felt in the armpit or upper arm. Breast pain may be described as: sharp, stabbing or shooting pain, feeling of heaviness or fullness in the breast, aching, tenderness, burning, or pinching. (Canadian Cancer Society, 2016) Kayla is having right breast tenderness that is now spreading to the axilla. Cysts of right breast (N60.01) - A woman can have one or many breast cysts. The signs and symptoms of a breast cyst may include: Lump(s) in the breast that feel smooth, soft and moveable, the edges of the cyst are very distinct from the surrounding breast tissue or lump(s) that becomes larger, tender and painful before or during a woman’s period. The lump and pain may decrease after the period. (Canadian Cancer Society, 2016) Kayla is having right breast tenderness that is now spreading to the axilla. Contusion of right breast (922.0) - A breast contusion occurs from a blow to the breast resulting in injury to the small blood vessels that are plentiful throughout the breast. Symptoms include breast pain redness, swelling, tenderness, with discoloration progressing from red, to black and blue, to green and then to yellow. A significant bruise can result in a hard breast lump within the breast that doesn't always go away. (Canadian Cancer Society, 2016) Kayla is having right breast tenderness that is now spreading to the axilla. Malignant neoplasm of right breast (C50.911) - According to the American Cancer Society, any of the following unusual changes in the breast can be a symptom of breast cancer: swelling of all or part of the breast, skin irritation or dimpling, breast pain, nipple pain or the nipple turning inward, redness, scaliness, or thickening of the nipple or breast skin, a nipple discharge other than breast milk, or a lump in the underarm area. (BreastC, 2016) Kayla is having right breast tenderness that is now spreading to the axilla and her paternal grandmother died of breast cancer at age 50. Acute vaginitis (Vulvovaginitis) (N76.0) -The symptoms of vulvovaginitis vary and depend on their cause. In general, symptoms can include: Irritation of the genital area, itching, inflammation around the labia and perineal areas, an increased, strong-smelling vaginal discharge, or discomfort while urinating. (Schuiling & Likis, 2013). Kayla complains of vaginal itching. Herpes viral infection of urogenital system, unspecified (A60.00) – The symptoms include itching, pain and the appearance of small sores (Schuiling & Likis, 2013). Kayla complains of vaginal itching. This study source was downloaded by from CourseH on :57:27 GMT -05:00 This study resource was shared via CourseH Encounter for screening for HPV (Z11.51) - One symptom of HPV is vaginal itching (Schuiling & Likis, 2013). Kayla complains of vaginal itching. References BreastC. (2016). Symptoms of Breast Cancer. Retrieved from Canadian Cancer Society. (2016). Breast Pain (Mastalgia). Retrieved from Schuiling, K. & Likis, F. (2013). Women's gynecologic health (Second ed.). Burlington, MA: Jones & Bartlett Learning, LLC. Discussion Part Two (graded) Further Data Vital Signs: Height: 160cm Weight: 70 kg, B/P:120/62, T: 99.2, HR: 100, Resp: 16, reg, nonlabored, SpO2: 99% General: Awake, alert, appropriate; well groomed; skin: warm, dry, intact. HEENT: Head normocephalic. Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic membranes intact, unremarkable; nares patent, unremarkable bil; pharynx unremarkable tonsils 2/4 bil; neck supple w/o lymphadenopathy. Breast Exam: Tanner IV female with large pendulous breasts bil. No nipple discharge. No nodules. Tenderness and erythema in a 6cm oval area to the right breast in the upper outer quadrant and into the tail of Spence. Right axilla lymphadenopathy noted. Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored; abdomen, soft, with normoactive bowel sounds throughout. Abdomen: Normoactive bowel sounds throughout; tenderness to palpation in the super-pubic area; no masses or organomegally; peripheral pulses reg., equal, intact; pelvic exam reveals sl. injected vaginal mucosa with a moderate whitish discharge. Erythema to the inside of the labia minora also noted. Urinalysis in the office: Cloudy amber yellow urine, Sp. Gr. 1.010, positive WBCs, nitrites, and leukoesterase; negative for RBCs, glucose, and ketones. This study source was downloaded by from CourseH on :57:27 GMT -05:00 This study resource was shared via CourseH Wet mount: Positive for Spores, Hyphae and clue cells. ***You note in the chart that Kayla never responded to your contact about her PAP results from several weeks ago. Her results showed ASCUS Discussion Questions Part Two What is the primary diagnosis for Kayla with rationale? Mastitis (91.22)- Mastitis is a swelling of the breast that is usually caused by an infection. Women with mastitis may have pain with a tender, red, wedge-shaped area on the breast. They may also have fever and chills, or they may feel tired and sick (AFP, 2016). Kayla is having right breast tenderness that is now spreading to the axilla. Mastodynia (N64.4) - Breast pain is usually associated with a benign breast condition; it is rarely a sign of breast cancer. Pain may be felt in one or both breasts, or just in part of one breast. Pain may also be felt in the armpit or upper arm. Breast pain may be described as: sharp, stabbing or shooting pain, feeling of heaviness or fullness in the breast, aching, tenderness, burning, or pinching. (Canadian Cancer Society, 2016) Kayla is having right breast tenderness that is now spreading to the axilla. Urinary tract infection (N39.0) – an infection of the urinary tract, symptoms include; dysuria, frequency, urgency and suprapubic or flank discomfort, and in some women they are only tired or fatigued (Goroll & Mulley, 2014). Positives- UA is positive for positive WBCs, nitrites, leukoesterase, and fatigue. Cervical dysplasia (N87.0) - Kayla has ASCUS which stands for atypical cell of undetermined significance, she has abnormal cervical cells. With this result the provider should next check for the presents of the virus human papillomavirus (HPV) (Fontaine, Saslow, & King, 2012). Acute vaginitis (N76.0) - this is inflammation of the vagina that causes abnormal discharge, irritation, itching and/or odor (Schuiling & Likis, 2013). Diagnosis is made by Ph greater than 4.5, positive whiff test, milky discharge, and the presence of clue cells on microscopic exam (Hainer, Gibson, 2011). Positives- moderate white discharge, erythema, and clue cells. Candidiasis of vulva and vagina (B37.3) - this can cause vaginal itching, burning and thick white discharge from the vagina (Schuiling & Likis, 2013). Positives- moderate white discharge, erythema, spores and hyphae. What is the differential diagnosis with rationale? This study source was downloaded by from CourseH on :57:27 GMT -05:00 This study resource was shared via CourseH Encounter for screening for human papillomavirus (HPV) (Z11.51) - Kayla has ASCUS which stands for atypical cell of undetermined significance, she has abnormal cervical cells. With this result the provider should next check for the presents of the virus human papillomavirus (HPV) (Fontaine, Saslow, & King, 2012). Trichomoniasis (A59.9)- Greenish-yellow, frothy vaginal discharge with a strong odor, painful urination, vaginal itching and irritation, discomfort during intercourse, lower abdominal pain (rare). Cellulitis (N61)- A bacterial infection of the skin that involves the deeper subcutaneous layers. It presents with localized redness, heat, swelling and tenderness that develops over a few days. Fever, chills and rigors may precede the cellulitis. Red streaks extending proximally in conjunction with tender lymph nodes indicate an associated lymphangitis (Goroll, Mulley, 2014). Malignant neoplasm of right breast (C50.911) - According to the American Cancer Society, any of the following unusual changes in the breast can be a symptom of breast cancer: swelling of all or part of the breast, skin irritation or dimpling, breast pain, nipple pain or the nipple turning inward, redness, scaliness, or thickening of the nipple or breast skin, a nipple discharge other than breast milk, or a lump in the underarm area. (BreastC, 2016) Kayla is having right breast tenderness that is now spreading to the axilla and her paternal grandmother died of breast cancer at age 50. Plan for each primary diagnoses based on one current evidence-based guidelines. Include the following: Further diagnostic work-up not included above Diagnostics- Urine HCG (to rule out pregnancy for appropriate treatment), Ultrasound of right breast, diagnostic mammogram of right breast (looking for abscess, cyst or neoplasm), CBC (evaluate infectious markers), Litmus testing for PH (PH 4.5 bacterial vaginosis and trichomoniasis), Saline wet mount vaginal fluid (presence of flagellated pyriform protozoa, or trichomonads, indicates a positive test result) (Fenstermacher & Hudson, 2016). HPV test (she has ASCUS) (Fontaine, Saslow, & King, 2012). Medications Metronidazone (Flagyl) 500mg tablet to treat bacterial vaginosis and possible trichomoniasis. Take 1 tablet PO BID x 7 days Disp: 14, Refills: 0 (Hainer & Gibson, 2011). Butoconazole vaginal 2% cream (OTC) to treat candidiasis of vulva and vagina. Insert 5g (one applicator full) into the vagina one daily at night x 3 days (Hainer & Gibson, 2011). This study source was downloaded by from CourseH on :57:27 GMT -05:00 This study resource was shared via CourseH Trimethoprim/sulfamethoxozole 160/800 tablets to treat urinary tract infection. 1 tablet BID x 3 days Disp: 6 tablets, Refill: 0 (Epocrates, 2015) Referrals OB/GYN for further evaluation of her ASCUS. Possible referral to a surgeon for biopsy of the right breast depending on ultrasound of breast. Possible referral to an oncologist depending on ultrasound and mammogram results. Conservative measures Wear loose-fitting clothes and all cotton underwear to prevent moisture sitting around the genitalia. Remove sweaty or wet clothing as soon as possible, avoid baths and harsh or heavily scented soaps to the genitalia (Fenstermacher & Hudson,