1-What further questions do you have for this patient during this visit? (These questions will help you to narrow your differential diagnosis)
2-What is your differential (ICD-10 Codes) diagnosis list for this visit? include at least 2 assessment and your primary ICD10
3. What would be your plan for this patient? (diagnostic work-up, Medications, Referrals, Conservative measures, Patient education, Follow-up plan, etc.)
Note: Please use proper references and rationales for your differential Diagnosis (ICD10) and your plan of care.
The patient already answered questions regarding the mass location (Upper, outer quadrant of her right breast), sensibility (painless), size (Marble size) and mobility (moveable). However we need to know more information about the mass and I will ask more questions such as: if the mass is soft or hard, adhered to the skin or not, relation with menstruation cycle, characteristic of the breast skin and nipple (skin changes, such as dimpling, inflammation, rashes, and nipple discharge, unilaterally retraction or inversion ), and presence or not of adenopathy. It is also important to ask question about previous breast biopsy, surgery or trauma and family, and personal history of breast disease/cancer. presence or not of general signs and symptoms such as: recent unintended weight loss, fatigue, fever, chills, malaise, weakness and/or night sweats. Knowing the patient age is also important, since under age 30, ultrasonography is the initial study of choice to evaluate the mass and Women age 30 or older require diagnostic mammography. All this additional information will help with making a good differential diagnosis. In my differential diagnosis we will see the importance of these questions.
Primary diagnosis: N63.11 Unspecified lump in the right breast upper outer quadrant. Some changes with body chemistry can affect the sensations and texture of the breast, and they can impact the development of breast lumps. They can be benign or malign. breast lumps can feel differently, cause by different etiology and have different prognostic. Benign lesions tend to have discrete, well-defined margins and are typically mobile, while Malignant lesions may be firm, may have indistinct borders, and are often immobile (Reid, 2018).
N76.0 Acute vaginitis: Patient complained of itching and burning sensation in the vaginal area, presence of a gray-white color discharge with a fishy, foul rotten odor. She reported that her husband is having unprotected sex with other sexual partners while he does not use condom with her (Korenromp E &al 2017).
E66.3 Overweight: BMI of 29.8 was reported.
For the purpose of the class I will discuss the presence of breast mass. However, I would examine the patient holistically as her health provider.
N60.01- Solitary cyst of right breast
A breast cyst is a benign, or noncancerous, fluid-filled sac in the breast. Breast cysts are smooth but firm. It often feels smooth and rubbery under the skin. It may be painless or quite painful. It is not clear what causes breast cysts, but they may develop in response to hormones related to menstruation. Breast cysts are rare in women aged over 50 years. Cysts can range in size from very small, only visible on an ultrasound scan, to between 2.5 and 5 centimeters. Large cysts can put pressure on other tissue, and this can be uncomfortable (Huizen, 2018).
N61.0 - Mastitis without abscess
Mastitis, an infection of the breast, is often accompanied by redness, swelling, and pain. Sometimes it may be difficult to distinguish between mastitis and inflammatory breast cancer, which usually begins with redness, tenderness, and a rash, rather than a lump (Medscape, October 2019).
N60.21 - Fibroadenosis of right breast
An adenoma is an abnormal growth of the glandular tissue in the breast. Fibroadenomas are the most common types of adenoma in the breast, and they tend to affect women under the age of 30 years, but they may occur in older women too. They account for 50 percent of breast biopsies, but they do not usually become cancerous. They are usually painless, easily movable, smooth, rounded and can disappear on their own (Huizen, 2018).
N64.1 - Fat necrosis of the breast
It is a benign, fatty tumor. Noncancerous lumps can form in the breast. They may be painful even though this is not always the case. nipple discharge and a dimpling of the skin over the lump might be present. It is soft lump, generally movable. The most frequent causes are history of physical trauma, surgery (removal of breast implants), radiation, women who are obese and have very large breasts. Other characteristics of an area or areas of fat necrosis include lumps that appear red or bruised in the skin around the lump, nipple retraction due to fat necrosis in the breast may be present (Huizen, 2018).
C50.421 - Malignant neoplasm of upper-outer quadrant of right male breast
The American Cancer Society reports that “most breast cancer cases first present as a new mass or lump. Age, gender, and ethnicity are the biggest risk factors. For women, the risk increases with age, and white women are at a higher risk than women of other races. A breast cancer lump or tumor usually feels hard or firm. It typically has an irregular shape, and it may feel as if it is stuck to the skin or deep tissue within the breast. Breast cancer is not usually painful, especially in the early stages. It can develop in any part of the breast or nipple, but it is most common in the upper outer quadrant. Some malignant tumors are painful. This can happen when they are large, and if they cause other structures in the breast to be compressed, or if they ulcerate or grow through the skin […] Other local symptoms may also appear in breast cancer, including breast or nipple pain, swelling, irritation, or color change of the breast or nipple retraction, a sore on the breast or nipple that will not heal, tender or enlarged glands under the arm or in the neck area, nipple discharge. a hoarse, persistent cough change in appetite, difficulty swallowing, pain after meals, unexplained weight gain or loss, night sweats, a general feeling of weakness or tiredness (Huizen, 2018).
After carrying out a careful physical examination, mammogram (depending of patient age) and/or ultrasound are ordered in this case, checking characteristics of the lump.
If the origin of the lump is cystic or a fibrous, we may monitor the lump but not taking any further action if not needed. If abscess is present, it might need to be drained with a fine needle, and antibiotics will be prescribed. A biopsy may be taken If cancer is suspected. In case the lesion is malign, treatment usually involves surgery and chemotherapy or radiation therapy, depending on the stage of the cancer. A test for changes in the BRCA1 or BRCA2 genes may be recommended. If this gene is present and breast cancer has occurred, preventive surgery may be an option to prevent a recurrence (Huizen, 2018).
Urinalysis and urine culture, vaginal Ph and wet mount, gonococcal culture, chlamydia smear, NAAT (swabs/urine), Gram stain, HIV (Korenromp et al, 2017).
Diagnosis and plan of care was discussed at length with patient. We discussed the importance of continuing the monthly self-exam of the breasts and the best technic to do so. We discussed that the most common tools for analyzing breast lumps are clinical breast exams, mammography, breast MRIs, and biopsies (Huizen, 2018). Patient was educated on the importance of avoiding smoking and excessive alcohol. I also educated patient e on the characteristics of STIs and the importance of using condoms to avoid STI and non-desire pregnancy. Patient was advised to call the office if she has any question/ concern or if she notices any alarm change in the characteristic of the lump. Patient is advised to come with her wife in the office during the next visit for counseling, evaluation and treatment as needed. Diet (low fat and sodium, high fiber), activity, exercise, possible medication side effects and interactions were reviewed.
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All pertinent questions were answered. Patient was advised to go to the nearest emergency room or call 911 in case of severe change in condition or medical problem. Patient will be seen within two weeks after appointment with specialist for consultation follow up, seeing the test results, medication review and reconciliation, and re-evaluation.
- Breast Cancer Differential Diagnoses. (2019, October 1). Retrieved from https://emedicine.medscape.com/article/1947145-differential.
- Huizen, J, (2018, July 25). Breast cancer: Lumps, causes, and risk factors. Retrieved from https://www.medicalnewstoday.com/articles/313490.php?iacp.
- Korenromp, E. L., Wi, T., Resch, S., Stover, J., & Broutet, N., (2017). Costing of National STI Program Implementation for the Global STI Control Strategy for the Health Sector, 2016-2021. Plos One, 12(1). doi: 10.1371/journal.pone.0170773
- Reid, C. M., Grigorian, A., Virgilio, C. D., & Hari, D. M., (2015). New Palpable Mass in Right Breast. Surgery, 25–36. doi: 10.1007/978-1-4939-1726-6_3
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