Management Of Women’s Health Issues Week 3 – Signature Assignment: iHuman Patient Betty Burns Reflection
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Explain How You Arrived At Your Differential Diagnoses
Diseases are characterized by patterns of symptoms reported by patients, the signs obtained during physical exam, and the results obtained from diagnostic tests. According to Dunphy (2019), determining the differential diagnoses is a process of distinguishing between diseases which present with the same symptoms. In Betty Burns’ iHuman case study, I arrived at the differential diagnosis using a systematic approach through the following steps; generating a list of Betty Burn’s medical issues through history taking, a physical exam, and evaluating the findings of the laboratory tests. Burns’ chief complaint was a lump on her left breast for about one month. The most common problems which present with this symptom among women aged 40 years or older are; fibroadenomas, breast lipoma, breast hamartoma, and breast adenocarcinoma. Using a local anatomic differential diagnosis framework and applying to it the pertinent positives and negatives resulted in the following differentials;
- Fibroadenoma-presents as a painless, benign and firm lesion
- Fibrocystic Breast Disease: it usually presents with changes in breast tissue such as lobular hyperplasia and cysts that are smooth and movable (Schuiling & Likis, 2017).
- For Betty Burns, the physical exam was also consistent with mild fibrocystic disease.
- Breast Cancer-Betty Burns’ breast biopsy findings was significant for an invasive ductal carcinoma with nuclear pleomorphism which is indicative of breast cancer.
Steps Used To Determine the Final Diagnosis
- To determine the final diagnosis, I identified the disease that accounted for all of Betty Burn’s problems from the initial list of differential diagnoses and was supported by the diagnostic test findings. The most appropriate diagnosis that met this criterion was breast mass/lump, neoplastic. Betty Burns was 48 years old and had a family history of breast cancer (mother). The risk of breast cancer increases in women aged 40 years and older (Schuiling & Likis, 2017). . She reported discoloration near the left breast nipple, an immobile lump on the left breast with thickening and indentations over the area with the lump. She also reported occasional bloody discharge in the cup of bra of the left breast. The physical exam findings were consistent with dimpling of the skin of the left breast, a fixed and firm mass (3cm) palpated at the 9 o’clock position, and bloody nipple discharge. The diagnostic breast biopsy was positive for an invasive ductal carcinoma, HER2 positive with evidence for metastasis (2 out of 2 left axillary lymph nodes positive for metastatic spread).
How To Integrate Cultural Preferences, Values, Health Beliefs, and Behaviors Into the Treatment Plan Using Watson’s Theory
Watson bases her theory of caring on seven major assumptions starting with the notion that caring can only happen at an interpersonal level between nurses and patients. Oher assumptions posit that caring leads to growth of the patient and family, patient satisfaction, needs acceptance, is the core of nursing, and creates an environment where individuals make wide decisions (Pajnkihar, Štiglic & Vrbnjak, 2017). Basing on the aforementioned assumptions, she mentions 10 Carative factors that nurses can implement in practice to; instill hope, develop trust, develop values, incorporate science to address issues, support a positive mental, physical, social, and spiritual environment, continuous learning, and help with physical needs (Pajnkihar, Štiglic & Vrbnjak, 2017). Applying this theory to the care of Betty Burns, I will develop a helping-trusting relationship and allow her to share both her positive and negative feelings, being authentic to, engage Betty Burn in genuine teaching-learning experience about her health status, and try to address her spiritual and physical needs by being open to discussions and matters spirituality.
Appropriate Management (Health Maintenance, Diagnostics, Medications/Treatment)
- Non-pharmacological treatment: refer for modified radical left mastectomy and axillary dissection/removal of suspicious lymph nodes.
- Pharmacological treatment: refer for radiation or/and chemotherapy (HER2 antagonist therapy (trastuzumab) (Schuiling & Likis, 2017).
- Patient Education: breast cancer and gynecological follow up in six months, lifelong cancer surveillance screening (clinical breast exam every 6-12 months), MRI/mammogram every 6-12 months.
- Diagnostics:
- Genetic Testing (BRCA)-No mutation detected.
- Left breast biopsy with lymph node biopsy- Invasive ductal carcinoma with nuclear pleomorphism. Mitotic counts: score 2. Estrogen receptor negative. Progesterone receptor negative. HER2 receptor positive.
- CT of abdomen and chest
- Diagnostic mammogram- Left breast BI-RADS 5, (3 cm irregular shaped mass in upper outer quadrant worrisome for malignancy). Right breast BI-RADS 1, normal.
- Breast ultrasound-Left breast solitary mass measuring 3 cm X 3.2 cm X 3.0 cm at 9 o’clock upper outer quadrant. Some skin thickening overlying the mass was also noted. In the left axilla 2.0 cm X 1.8 cm X 2.0 cm lymph node was identified, suspicious for malignancy.
- BMP
- Lipid Panel
- Referral to an oncologist for further evaluation and management
Overall Case Evaluation and Takeaways
In my next assessments, I will be keener to conduct a more focused history taking and physical exam based on a patient’s presenting complaint. A focused history using focused questions and a focused physical exam will provide more comprehensive and direct clues of a patient’s most probable diagnosis. When compared to past assessments, I must admit that my history taking and physical exam techniques have tremendously improved. Besides, I can effortlessly incorporate pathophysiology knowledge that I have obtained in class in clinical and diagnostic reasoning to determine the appropriate tests to order and make appropriate diagnoses.
References
Dunphy, L. (2019). Primary care: The art and science of advanced practice nursing (5th ed.). F.A. Davis.
Pajnkihar, M., Štiglic, G., & Vrbnjak, D. (2017). The concept of Watson’s carative factors in nursing and their (dis)harmony with patient satisfaction. PeerJ, 5, e2940. https://doi.org/10.7717/peerj.2940
Schuiling, K. D., Likis, F. E. (2017). Women’s gynecologic health (3rd ed.). Jones & Bartlett Learning.