NRP/563: Management Of Women’s Health Issues – Betty Burns iHuman Reflection

NRP/563: Management Of Women’s Health Issues – Betty Burns iHuman Reflection

SOAP Note: Betty Burns

Subjective:

Mrs. Betty Burns, a 48-year-old female, presents with a chief complaint (CC) of a lump on her left breast persisting for approximately one month. This information is documented in relation to the NRP/563 course, focusing on the management of women’s health issues.

History of Present Illness (HPI):

Mrs. Burns reports additional active health concerns, including well-controlled hypertension managed with Hydrochlorothiazide. Childhood asthma occasionally flares, requiring oral steroids. Seasonal allergies are under control, and she has a history of mild fibrocystic disease. Obstetrically, she is Gravida 2, Para 2, Abortus 0, with her first child at age 36 and the second at age 38. Past surgical history includes an appendectomy over 20 years ago and tubal ligation after the birth of her second child. Mrs. Burns follows preventive measures such as yearly flu immunizations, maintaining a recommended weight of 150 lbs. to achieve a BMI of 24.2, and regular mammograms. She adheres to safety practices like regular seat belt use and abstains from texting while driving. Immunizations are up to date, including Tdap, influenza, and pneumovax administered at age 42 due to her asthma. A recommendation for shingles vaccination is suggested at age 60. Family history notes her mother’s breast cancer at age 55, with no known medical history for her father, siblings, or grandparents. Socially, Mrs. Burns is a non-smoker with minimal secondhand smoke exposure, occasional social alcohol consumption, and no history of recreational drug use. She is in a monogamous marriage with two daughters, ages 8 and 10. Educationally, she is a college graduate working as an elementary-school principal, reporting no recent travel or pet ownership. Her home is firearm-free. Eating habits include most meals consumed at home, fast food once a week, and walks for exercise 1-2 times weekly.

Review of Systems (ROS):

A comprehensive review covers general health, skin, head, eyes, ears, nose, throat (HEENT), neck, breasts, respiratory, cardiovascular (CV), gastrointestinal (GI), peripheral vascular, urinary, genital/Last Menstrual Period (LMP), musculoskeletal (MSK), psychological, neurological, hematologic, and endocrine systems. This helps in gathering a holistic understanding of Mrs. Burns’ health status.

ROS (general, skin, HEENT, neck, breasts, resp, CV, GI, peripheral vascular, urinary, genital/LMP, MSK, psych, neuro, hematologic, endocrine)

Comprehensive Health Assessment: Betty Burns

General Health: Ms. Burns denies evidence of fever, chills, fatigue, malaise, night sweats, or unexplained weight gain or loss.

Skin/Breasts: There are no reported issues such as rashes, bruising, jaundice, pruritis, acne, sores, ulcers, changes in moles, hair loss, or brittleness of nails. Ms. Burns mentions no pain in her breasts but reports the presence of a lump on the left breast for one month, discovered during a self-breast exam. She notes discoloration near the nipple on the left breast, a thickened area over the lump with indentations, and occasional bloody discharge in her left breast cup of the bra. The last mammogram was 15 months ago, reported as normal. There is no observed movement with the lump, and menstrual cycles are regular every 26-28 days.

HEENT/Neck: Ms. Burns denies vision changes, blurred vision, eye pain, discharge, itching, or redness. She also denies ear pain, ear discharge, hearing difficulty, vertigo, nasal congestion, epistaxis, sinus pain or pressure, sore throat, swollen glands in the neck, and tooth pain.

Cardiovascular: No complaints of chest pain/pressure, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, palpitations, or ankle swelling.

Respiratory: Ms. Burns denies shortness of breath, wheezing, cough/sputum, hemoptysis, tightness in the chest, or pleuritic chest pain.

Abd/GI: There are no problems reported with appetite changes, dysphagia, nausea, vomiting, hematemesis, heartburn, abdominal pain, diarrhea, constipation, or melena.

GU: No menstrual irregularities, amenorrhea, dysmenorrhea, or dyspareunia. Denies dysuria, urinary frequency, nocturia, hematuria, incontinence, urgency, hesitancy, or difficulty starting or stopping the stream.

MSK: Ms. Burns reports no joint or muscle pains, joint stiffness and swelling, or limitations in movement or functionality.

Neuro: There are no reported issues with headaches, syncope, presyncope, dizziness, weakness, paralysis, numbness/tingling, or balance.

Allergic/Immunologic: Ms. Burns denies food allergies, hives, or rashes.

Lymphatic/Endocrine: There are no reported issues related to polyuria, polydipsia, polyphagia, tremor, heat or cold intolerance, or hot flashes.

Hematologic: Ms. Burns denies excess bruising or bleeding, swollen glands/lymphadenopathy.

Psychological: No problems are reported with mood changes, feeling depressed, manic behaviors, auditory or visual hallucinations, anxiety, insomnia, or suicidal or homicidal ideations.

Allergies: Seasonal hay fever. No known drug allergies. No known food allergies.

Current Medications:

  1. Fluticasone (Flonase): One spray each nostril every morning as needed for seasonal allergies.
  2. Fluticasone/salmeterol 250/50: One puff twice daily for asthma.
  3. Hydrochlorothiazide (HCTZ): 25 mg orally daily for hypertension.

Objective: Vital Signs:

  • Heart Rate (HR): 80 beats per minute, regular rhythm.
  • Blood Pressure (BP):
    • Supine/sitting: 128/80 mmHg.
    • Upon standing: 126/72 mmHg.
  • Pulse: 80 beats per minute, regular rhythm.
  • Respiratory Rate (RR): 16 breaths per minute, unlabored.
  • Pain: 0 (on a scale of 0 to 10).

Physical Measurements:

  • Height: 5’ 6”
  • Weight: 165 lbs. (75 kg)
  • Body Mass Index (BMI): 26.26

Temperature: 98.6°F oral

Pulse Oximetry: 99% on room air.

Physical exam (general, HEENT, neck/lymph, breasts, chest/respiratory, CV, GI/abdomen, GU/rectal, back, MSK, skin, neuro, psych)

In the assessment of Betty Burns:

Weight: Betty weighs 165.0 pounds.

Skin/Breasts: Her skin appears atraumatic with good turgor, normal scalp, and no suspicious pigmented lesions. The breast exam indicates mild fibrocystic disease, left breast exhibiting subtle skin dimpling (peau d’orange appearance). Both breasts have a normal symmetrical contour with no overt inflammatory signs. In the left breast, a firm, fixed, 3 cm mass is palpated at the 9 o’clock position, accompanied by subtle skin dimpling. Smaller palpable nodules consistent with fibrocystic disease and history are found. Expressible bloody nipple discharge is noted. In the left axilla, there is a solitary, nontender, mobile, 2 cm lymph node. The right breast has small palpable nodules consistent with prior exams and known fibrocystic disease, without axillary adenopathy or expressible nipple discharge.

HEENT: Eyes, ears, nose, and mouth present with no abnormalities. The neck is supple with no adenopathy, midline trachea, normal thyroid size, and no masses or tenderness.

Cardiovascular: No jugular venous distention, thrills, heaves, or lifts. The heart is regular with normal S1 and S2, no murmurs appreciated. No carotid bruits, and normal peripheral pulses without evidence of edema or varicosities.

Respiratory: Normal chest shape and movement, no tenderness, and normal breath sounds without wheezing, rales, or rhonchi.

Abdomen/GI: Flat contour with normal scars. Normal bowel sounds, soft to palpation without tenderness, liver edge felt below the coastal margin, normal spleen size, and no masses or organomegaly.

GU: Normal genitalia, no signs of infection, and normal ovaries on palpation. A Pap smear has been performed.

MSK: Normal range of motion and muscle tone throughout, with normal strength and flexibility in both axial and appendicular skeleton. Motor strength is 5/5 in all extremities.

Neurological: Alert and oriented, good attention and memory, normal gait, intact cranial nerves (CN 2-12), reflexes 4/4 throughout, and a normal cerebellar exam with finger-to-nose, rapid alternating movements, and heel-to-shin bilaterally.

Allergic/Immunologic: No concerning lymph nodes in various regions.

Lymphatic/Endocrine: Normal thyroid to palpation with no masses or tenderness.

Hematologic: Capillary refill is normal, and there is no evidence of anemia.

NRP/563- Management Of Women’s Health Issues – Betty Burns iHuman Reflection

Assessment

Problem List:

  • Breast mass/lump, neoplastic
  • Invasive ductal carcinoma, left breast ER/PR negative, HER2 positive
  • Evidence of metastasis: 2 out of 2 left axillary lymph nodes positive for metastatic spread
PlanRationale and/or Results
Breast Cancer Susceptibility Genetic Test (BRCA1 and BRCA2)No mutation detected.
Diagnostic mammogramLeft breast BI-RADS 5, indicating a 3 cm irregular-shaped mass in the upper outer quadrant, worrisome for malignancy. Right breast BI-RADS 1, normal.
Left breast biopsy with lymph node biopsyRevealed invasive ductal carcinoma with nuclear pleomorphism. Mitotic counts: score 2. Estrogen receptor negative. Progesterone receptor negative. HER2 receptor positive.
Breast ultrasoundDetected a 3 cm X 3.2 cm X 3.0 cm solitary mass in the left breast at 9 o’clock upper outer quadrant. Skin thickening overlying the mass and a 2.0 cm X 1.8 cm X 2.0 cm lymph node in the left axilla, suspicious for malignancy.
Surgical referral for modified radical left mastectomy and axillary dissectionIndicated for the removal of the suspicious mass and lymph nodes.
Radiation referral for therapyEssential for post-surgical treatment.
HER2 antagonist therapy (trastuzumab)Targeted therapy for HER2-positive breast cancer.
Oncology referralTo discuss comprehensive treatment options.
Referral for education, counseling, supported decision-making, and support groupsEnsures a holistic approach to patient care, providing necessary resources and emotional support.
Life-long cancer surveillanceNecessary for monitoring and early detection of any recurrence.
Lab to check lipid panel and BMPTo assess baseline values and monitor potential treatment-related effects.

NRP/563: Management of Women’s Health Issues

Wk 3 – Signature Assignment: Patient Betty Burns ihuman Reflection

I reviewed the SOAP note for Betty Burns, a 48-year-old female presenting with a lump on her left breast. During the encounter, I carefully gathered information about her medical history, surgical history, family history, and social aspects, which included her active problems like well-controlled hypertension and childhood asthma. Betty’s obstetric history revealed two pregnancies, with the first child born at 36 and the second at 38. Her surgical history included an appendectomy over 20 years ago and tubal ligation after the birth of her second child.

In my initial assessment, I considered her preventive care, including flu immunization, weight management recommendations, and regular mammograms. Betty’s family history included her mother having breast cancer at the age of 55, with no known medical history for her father, siblings, or grandparents. Socially, Betty is monogamous, has two daughters, is a college graduate, and works as an elementary school principal.

For the physical examination, I evaluated Betty’s vital signs, general appearance, skin, breasts, head, eyes, ears, nose, mouth, neck, cardiovascular and respiratory systems, abdomen, genital and urinary systems, musculoskeletal system, neurological system, and allergic/immunologic aspects. These assessments allowed me to rule out any abnormalities or concerns, providing a comprehensive understanding of Betty’s health.

The problem list identified a neoplastic breast mass, diagnosed as invasive ductal carcinoma in the left breast, ER/PR negative, and HER2 positive. Two out of two left axillary lymph nodes were positive for metastatic spread, indicating evidence of metastasis.

To arrive at the differential diagnoses, I considered possibilities such as breast hamartoma, fibroadenoma, and breast lipoma. These were ruled out based on the results of diagnostic tests, including the diagnostic mammogram, breast biopsy, and breast ultrasound, which collectively confirmed the invasive ductal carcinoma.

The management plan involved a referral for genetic testing, diagnostic mammogram, breast biopsy, breast ultrasound, surgical referral for mastectomy and lymph node removal, radiation therapy, HER2 antagonist therapy (trastuzumab), oncology referral, education and counseling, and life-long cancer surveillance. These interventions were based on evidence and guidelines.

In integrating cultural preferences and values into the treatment plan, I considered Watson’s theory, emphasizing patient-centered care. This involves understanding Betty’s cultural background, preferences, and values, and incorporating them into her care plan. For instance, providing educational materials in a language she is comfortable with and involving her family in decision-making aligns with patient-centered care.

How to Incorporate Cultural Preferences, Values, Health Beliefs, and Behaviors into the Treatment Plan Using Watson’s Theory

Watson’s caring theory is built on seven key assumptions, with a fundamental premise being that caring occurs at an interpersonal level between nurses and patients. Other assumptions underscore the idea that caring contributes to the growth of patients and their families, satisfaction, needs acceptance, forms the core of nursing, and establishes an environment conducive to individuals making informed decisions (Pajnkihar, Štiglic & Vrbnjak, 2017).

Based on these assumptions, Watson identifies 10 Carative factors that nurses can apply in practice to foster hope, build trust, shape values, integrate science to address issues, support positive mental, physical, social, and spiritual environments, encourage continuous learning, and assist with physical needs (Pajnkihar, Štiglic & Vrbnjak, 2017). In the case of Betty Burns, implementing this theory involves establishing a helping-trusting relationship, allowing her to express both positive and negative feelings authentically, engaging her in a genuine teaching-learning experience about her health status, and addressing her spiritual and physical needs through open discussions about spirituality (NRP/563: Management of Women’s Health Issues – Betty Burns iHuman Reflection).

Appropriate Management (Health Maintenance, Diagnostics, Medications/Treatment)

For Betty Burns, the recommended management involves both non-pharmacological and pharmacological treatments. The non-pharmacological approach includes referring her for a modified radical left mastectomy and axillary dissection to remove suspicious lymph nodes. On the pharmacological side, she should be referred for radiation and/or chemotherapy, specifically HER2 antagonist therapy (trastuzumab) (Schuiling & Likis, 2017).

Patient Education is a crucial aspect, emphasizing follow-ups every six months for breast cancer and gynecological assessments. Lifelong cancer surveillance screenings are recommended, involving clinical breast exams every 6-12 months and MRI/mammogram checks every 6-12 months.

Diagnostics play a vital role in Betty’s case:

  1. Genetic Testing (BRCA): No mutation detected.
  2. Left breast biopsy with lymph node biopsy: Revealed invasive ductal carcinoma with specific characteristics (negative estrogen and progesterone receptors, positive HER2).
  3. CT of abdomen and chest
  4. Diagnostic mammogram: Left breast BI-RADS 5, indicating a worrisome irregular mass. Right breast BI-RADS 1, normal.
  5. Breast ultrasound: Detected a solitary mass in the left breast with suspicious lymph nodes in the left axilla.
  6. Basic metabolic panel (BMP)
  7. Lipid Panel
  8. Referral to an oncologist for further evaluation and management.

Overall Case Evaluation and Takeaways

This case highlighted the importance of a focused history and physical exam based on the patient’s complaint. Improved techniques in history taking and physical exams were evident in this assessment compared to previous ones. Incorporating pathophysiology knowledge into clinical reasoning enhanced the ability to order appropriate tests and make accurate diagnoses. Moving forward, maintaining a focus on these skills will be crucial in delivering effective patient care (Dunphy, 2019).

References:

Dunphy, L. (2019). Primary care: The art and science of advanced practice nursing (5th ed.). F.A. Davis.

Schuiling, K. D., Likis, F. E. (2017). Women’s gynecologic health (3rd ed.). Jones & Bartlett Learning.

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