Patient Case: Breast Feeding

Patient Case: Breast Feeding

Cite this
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. Patient Case: Breast Feeding
Medications:
Multivitamins and minerals. Tylenol for pain or fever.
PMHAllergies: 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 HistoryFather 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.

ORDER A PLAGIARISM – FREE PAPER NOW

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 Patient Case: Breast Feeding
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
  • Differential Diagnoses:
    1. ICD-10 Code: №O91.22 – nonpurulent mastitis associated with puerperium.
    2. ICD-10 Code: №O91.23 – nonpurulent mastitis associated with lactation.
    3. ICD-10 Code: №O92. – other disorders of breast and disorders of lactation.
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.Patient Case: Breast Feeding

Presumptive Diagnosis: Nonpurulent mastitis associated with lactation

Plan:

  • Treatment
  • Oral antibiotics to destroy the bacteria which causes the infection and preconditions the appearance of inflammatory processes (amoxicillin) (“Mastitis – Treatment,” n.d.).
  • Ibuprofen to reduce pain or fever.
  • Emptying the breast:
    • by breastfeeding (the patient can safely continue doing it)
    • by pumping the breast milk

Timely emptying of the breast affected by mastitis will prevent the further development of the infection and its spread.

Education

First 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

  • The patient should visit a physicist once a week during the recovery process.
  • Blood test in two weeks should be prescribed.
  • In case the problem is not solved, another oral antibiotic should be prescribed.
  • Breastfeeding should be monitored.
  • Surgery might be needed if no improvement of the patients state is observed.
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.

Cut 15% OFF your first order
We’ll deliver a custom Diagnostics paper tailored to your requirements with a good discount
Use discount
322 specialists online

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. Patient Case: Breast Feeding

What Will You Get?

We provide professional writing services to help you score straight A’s by submitting custom written assignments that mirror your guidelines.

Premium Quality

Get result-oriented writing and never worry about grades anymore. We follow the highest quality standards to make sure that you get perfect assignments.

Experienced Writers

Our writers have experience in dealing with papers of every educational level. You can surely rely on the expertise of our qualified professionals.

On-Time Delivery

Your deadline is our threshold for success and we take it very seriously. We make sure you receive your papers before your predefined time.

24/7 Customer Support

Someone from our customer support team is always here to respond to your questions. So, hit us up if you have got any ambiguity or concern.

Complete Confidentiality

Sit back and relax while we help you out with writing your papers. We have an ultimate policy for keeping your personal and order-related details a secret.

Authentic Sources

We assure you that your document will be thoroughly checked for plagiarism and grammatical errors as we use highly authentic and licit sources.

Moneyback Guarantee

Still reluctant about placing an order? Our 100% Moneyback Guarantee backs you up on rare occasions where you aren’t satisfied with the writing.

Order Tracking

You don’t have to wait for an update for hours; you can track the progress of your order any time you want. We share the status after each step.

image

Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

image

Trusted Partner of 9650+ Students for Writing

From brainstorming your paper's outline to perfecting its grammar, we perform every step carefully to make your paper worthy of A grade.

Preferred Writer

Hire your preferred writer anytime. Simply specify if you want your preferred expert to write your paper and we’ll make that happen.

Grammar Check Report

Get an elaborate and authentic grammar check report with your work to have the grammar goodness sealed in your document.

One Page Summary

You can purchase this feature if you want our writers to sum up your paper in the form of a concise and well-articulated summary.

Plagiarism Report

You don’t have to worry about plagiarism anymore. Get a plagiarism report to certify the uniqueness of your work.

Free Features $66FREE

  • Most Qualified Writer $10FREE
  • Plagiarism Scan Report $10FREE
  • Unlimited Revisions $08FREE
  • Paper Formatting $05FREE
  • Cover Page $05FREE
  • Referencing & Bibliography $10FREE
  • Dedicated User Area $08FREE
  • 24/7 Order Tracking $05FREE
  • Periodic Email Alerts $05FREE
image

Our Services

Join us for the best experience while seeking writing assistance in your college life. A good grade is all you need to boost up your academic excellence and we are all about it.

  • On-time Delivery
  • 24/7 Order Tracking
  • Access to Authentic Sources
Academic Writing

We create perfect papers according to the guidelines.

Professional Editing

We seamlessly edit out errors from your papers.

Thorough Proofreading

We thoroughly read your final draft to identify errors.

image

Delegate Your Challenging Writing Tasks to Experienced Professionals

Work with ultimate peace of mind because we ensure that your academic work is our responsibility and your grades are a top concern for us!

Check Out Our Sample Work

Dedication. Quality. Commitment. Punctuality

[display_samples]

It May Not Be Much, but It’s Honest Work!

Here is what we have achieved so far. These numbers are evidence that we go the extra mile to make your college journey successful.

0+

Happy Clients

0+

Words Written This Week

0+

Ongoing Orders

0%

Customer Satisfaction Rate
image

Process as Fine as Brewed Coffee

We have the most intuitive and minimalistic process so that you can easily place an order. Just follow a few steps to unlock success.

See How We Helped 9000+ Students Achieve Success

image

We Analyze Your Problem and Offer Customized Writing

We understand your guidelines first before delivering any writing service. You can discuss your writing needs and we will have them evaluated by our dedicated team.

  • Clear elicitation of your requirements.
  • Customized writing as per your needs.

We Mirror Your Guidelines to Deliver Quality Services

We write your papers in a standardized way. We complete your work in such a way that it turns out to be a perfect description of your guidelines.

  • Proactive analysis of your writing.
  • Active communication to understand requirements.
image
image

We Handle Your Writing Tasks to Ensure Excellent Grades

We promise you excellent grades and academic excellence that you always longed for. Our writers stay in touch with you via email.

  • Thorough research and analysis for every order.
  • Deliverance of reliable writing service to improve your grades.
Place an Order Start Chat Now
image