| Name:R.H. | S O A P | Time:1.40 p.m. | |
| Date:9/30/2017 | Age:30 y/o | Sex:F | |
| SUBJECTIVE | |||
| CC: “I have left breast pain.” | |||
| HPI: Mrs. R.H. presents to the office complaining of having left breast pain starting 2 days ago. The pain radiates to left arm and neck, is dull 3-4 / 10 decreases when taking Tylenol. She also has malaise and fever, nausea and is worried because is breast feeding to her new born having 25 days after her first uncomplicated delivery. She is taking multivitamins and minerals as a supplements and Tylenol for pain and fever. She wants to know if she can breast feed her baby in this condition. | |||
| Medications: Multivitamins and minerals. Tylenol for pain or fever. | |||
| PMH Allergies: The patient states that she does not suffer from any environmental, food, or drugs allergies Medication Intolerances: There is no medical data about medication intolerances. Chronic Illnesses/Major trauma NONE OBGY G 1 P 1 Menarche 12 y.o | |||
| Family History Father is alive. Negative for cancer, heart disease, hypertension, tuberculosis, other medical illnesses. Mother is alive. Negative for cancer, heart disease, hypertension, tuberculosis, other medical illnesses | |||
| Social History The patient is socially active. She works as teacher. She does not use tobacco or drugs, or alcohol. She only has sexual activity with her husband. She has good family relations and husband. | |||
| ROS | |||
| General | Cardiovascular | ||
| She feels general malaise and fever for 2 days The patient gained weight during her pregnancy. She is now slowly back to her normal weight. | The patient does not have cardiovascular problems. She denies chest pain, edema, orthopnea, etc. In the course of the examination, no symptoms or problems are discovered. |
| Skin She reports redness on left breast | Respiratory There are no signs of problems. The patient deniesshortnessofbreath, cough,congestion,wheezing,hemoptysis,dyspnea,pneumonia.There is also no tuberculosis history. |
| Eyes There are no reported problems with sight. The patient denies blurring, visual changes of any kind.She does not visit ophthalmologists regularly because does not feel the need for it. | Gastrointestinal She has nausea last 2 days he has no complaints of gastrointestinal system. The patient denies hepatitis, hemorrhoids, eating disorders, ulcers, blacktarry stools. |
| Ears The patients hearing is fine. She has never experienced ear pain, hearing loss, ringing in ears, etc. There are no signs of ear traumas. | Genitourinary/Gynecological No complaints no bleeding no vaginal discharge no pelvic pain No history o fSTDs or vaginal infections. |
| Nose/Mouth/Throat The patient does not have any oral cavitys diseases. She denies a sorethroat, discharge,dysphagia,nosebleeds,dentaldisease,hoarseness. | Musculoskeletal The musculoskeletal development is normal. No signs of dystrophy. She denies trauma, backpain, hippain.Deniesfracture.The examination does not demonstrate any visible problems in the sphere. |
| Breast The patients c/o bilateral breast engorgement aand left breast pain 3- 4/10 radiated to left arm with increase of temperature milky bilateral dischargedyschargepatient denieslumps,bumpsorchanges.There is no breast cancer history in the family. | Neurological She does not experience spontaneous episodes of weakness, memory loss, mental problems, etc. | ||
| Heme/Lymph/Endo The patient is not a donor. She denies blood transfusion. There are no extreme sweating, alterations in her appetite, etc . | Psychiatric Denies depression, sleeping disorder, suicidal attempts, etc. | ||
| OBJECTIVE | |||
| Weight:162lbs BMI:29.6. | Temp:100.1tympanic | BP:130/87rightarmsitting | |
| Height:5’2 | Pulse:102 x min | Resp:14 x min. Oxy Sat 99% | |
| General Appearance Female not in distress looks ill, cooperative answers willingly and appropriately. | |||
| Skin The patients skin is of normal color. It is warm, clean, without spots or some other problems. Breast skin in the left is red and hot temperature. | |||
| HEENT The patients head is normocephalic. It is symmetric. There are no lesions. Her hair is distributed in accordance with the sex character. No tenderness. No signs of major traumas. The patients eyes demonstrate no signs of significant health problems. Pupils are equal, round and reactive to light and accommodation. Extraocular movements are intact. The sclera is clear. Ears: Landmarks are visualized. No signs of problems with hearing. Positive light reflex. Nose: No visible problems. Mucosa is fine and pink. There are no deviations. Neck: Pharynx is pink. Oral mucosa is fine. Problems with occlusion that should be corrected Teeth are fine. There are no nodules. Finally, no lymphadenopathy or thyromegaly are discovered. Oral mucosa is moist and pale pink | |||
| Cardiovascular No extra sounds are discovered during the patients investigation. The rate and rhythm are regular. Capillary refill – 1,6 seconds. There is noedema. | |||
| Respiratory The patients chest wall is symmetric. She demonstrates regular respirations. There are no problems with breathing. | |||
| Gastrointestinal The patients abdomen is round, soft. Responds to palpation in a normal way. Active in all quadrants. There are no signs of visible health problems. | |||
| Breast | |||
| Breast exam shoes left nipple edema erythema with nipple discharge, Cultures are taken No axillary regional nodes found Left breast erythema and tender to palpation. |
| Genitourinary External exam: Vulvais pink, without any traumas or signs of damage. There is no discharge on the walls. Episiotomy scar looks with normal Pelvic examination shows vaginal mucosa pink, no secretions, os closed. bimanual exam shows uterus retroverted no mases non tender. Adnexa is no palpable. Rectal exam demonstrates the absence of pain, mases or signs of traumas. No bleeding. |
| Musculoskeletal The patient demonstrates no pain when moves. All gestures are painless. The locomotor apparatus is fine. |
| Neurological The patients speech is clear. She responses to all answers in an appropriate way. Demonstrates an appropriate level of cognitive activity. Reflexes are intact. Balance is stable. No visible neurologic diseases. |
| Psychiatric The patient maintains the eye contact. Speech is clear. Understands all questions. Demonstrates anxiety because of the pain during menses. No visible signs of mental disorders. The family history also does not contain any records of this sort. |
| Lab Tests Brest ultrasound – a hypoechoic lesion in the left breast is found (Miller, 2017a).Well circumscribed, macrolobulated, irregular. Diagnostic needle aspiration drainage – fluid could be observed (Miller, 2017a).It indicates the abscess. Cytology of nipple discharge – proves the presence of infection and inflammation processes. Mammogram – nonspecific findings. Tuberculin skin test – positive with TB Blood test – indicates infection. Negative for cancer. CBC test – normal. No signs of severe diseases. Blood sugar test – positive for diabetes. |
| Special Tests– Biopsy of tissue – needed to discover the inflammatory process. No signs of breast cancer. |
| ASSESSMENT FINDINGS AND PLAN |
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| The main patients symptoms are the pain in the left breast and uncomfortable feelings during the breastfeeding. Additionally, nipple discharge can be observed. These factors could indicate problems with breasts and lactation. For this reason, there are the three differential diagnoses that should be considered when investigating the case. These are nonpurulent mastitis associated with puerperium, nonpurulent mastitis associated with lactation, and other disorders of breast and disorders of lactation. There are several causes for the appearance of these health problems. Infection is one of the most frequent ones. It appears when bacteria from a babys mouth enters a milk duct and affects the tissue (Bonyata, 2017). For this reason, it is crucial to examine a patient to find out if any infection is present. The patient denies any STDs or HIV, which means that her immune system is not weak. Her blood sugar level should be tested as diabetes is one of the main causes of the occurrence of the given health problem (Kataria, Srivastava, & Dhar, 2013). Considering all these facts, the above-mentioned diagnoses could be applied to the situation. However, the nonpurulent mastitis associated with lactation remains the most probable one. |
| There are several tests that should be applied to the case to prove the final diagnosis. First, the breast ultrasound is needed to discover lesions in the breast. The ultrasound could also help to locate the affected breast. It should be followed by the diagnostic needle aspiration drainage to observe the fluid and analyze it. Cytology of nipple discharge is also crucial as it helps to determine the type of mastitis and find the most appropriate treatment. A mammogram should be prescribed to avoid possible complications and assure that no tumors are found. Finally, CBC, blood, and tuberculin skin tests are needed to create the whole picture and choose the most appropriate treatment. |
Presumptive Diagnosis: Nonpurulent mastitis associated with lactationPlan:
Timely emptying of the breast affected by mastitis will prevent the further development of the infection and its spread. EducationFirst of all, the patient should be explained that mastitis does not damage breast milk and it still could be used to feed her baby. Moreover, it is crucial to continue breastfeeding as it is one of the best ways to prevent bacteria from collecting (“Mastitis while breast-feeding,” n.d.). For this reason, she should continue using both breasts. Sometimes babies could be reluctant to take the affected breast; however, it is not related to the quality of milk as it preserves its characteristics. The breast might feel different, and a baby could be confused by this feeling (“Breast infection,” n.d.). For this reason, a patient should be ready to pump the breast milk in case breastfeeding becomes impossible or too painful (Miller, 2017b). Furthermore, she should also be explained that her baby cannot become ill because of mastitis or bacteria that affects her breast. Finally, as diabetes is one of the causes for this health problems occurrence, the patient should be provided with the information about the disease. Follow-Up
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| Self-Assessment Investigating the case, we were able to discover the main factors related to mastitis and breastfeeding. The unique importance of the process and its impact on the health of a baby precondition the increased necessity of efficient treatment. For this reason, it is crucial to perform tests that will help to determine the type of mastitis and choose an appropriate approach. Additionally, the case provides the information about the causes of the occurrence of this health problem which is important for the functioning in the real-life setting. Finally, the necessity of breastfeeding and the patients education is also considered. |
References
Bonyata, K. (2017). Plugged ducts and mastitis. Web.
Breast infection. (n.d.). Web.
Kataria, K., Srivastava, A., & Dhar, A. (2013). Management of lactational mastitis and breast abscesses: review of current knowledge and practice. Indian Journal of Surgery, 75(6), 430-435. Web.
Mastitis – Treatment. (n.d.). Web.
Mastitis while breast-feeding – Treatment overview. (n.d.). Web.
Miller, A. (2017a). Breast abscesses and masses follow-up. Web.
Miller, A. (2017b). Mastitis empiric therapy. Web.