Case study 6: Part One

Overview: Kayla, a now 26-year-old Caucasian and Hispanic female, comes in the week after the children’s illness comOverview: Kayla, a now 26-year-old Caucasian and Hispanic female, comes in the week after the children’s illness complaining of fatigue, dysuria, and pain in her left breast, all occurring within the last few days.

HPI: The breast pain is burning and superficial. She has not noticed any nipple discharge. She has also had mild myalgia. The dysuria began a few days before the breast pain; right after her daughter came home from her appendectomy. She reports a great deal of stress. She has not been monitoring for a fever. She denies diarrhea or constipation, abdominal pain, skin changes, cough, or chest pain. She has not been sleeping well, due to having to stay with her daughter in the hospital. No recent physical or well woman exam since the birth of her son.

PMH: No surgical history; no trauma history; 10 year 1PPD smoker, smoking cessation 2 years ago;  gestational diabetes with last pregnancy; history of PCOS.

Social History: She continues to live with her parents during a separation from her husband and is working part time at the children’s school library but has not been there for over a week. She has no health insurance, but her children are now covered by the State Medicaid HMO.

Family History: Her paternal great grandmother died of breast cancer at the age of 50. Her mother has hypertension, hyperlipidemia, and type 2 diabetes. Her father has hypertension, hyperlipidemia, and cardiovascular disease.

FURTHER DATA

Vital Signs: Weight: 73 kilograms, B/P:120/62, T: 99.2, HR: 100, Resp: 16, reg, non-labored, SpO2: 99%

General: Awake, alert, appropriate;  well groomed; skin: warm, dry, intact, but there are three small 3-4mm erythematous bullous lesions noted at 9 o’clock on the left breast; HEENT: Head normocephalic.  Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic membranes intact, unremarkable; nares patent, unremarkable bil; pharynx unremarkable tonsils 2/4 bil; neck supple w/o lymphadenopathy.

Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored; abdomen, soft, with normoactive bowel sounds throughout. 

Breast Exam: No chest deformity or asymmetry noted; no palpable lesions, masses, or lymphadenopathy; skin exam to the breasts as above; no nipple discharge.

Abdomen: Normoactive bowel sounds throughout; tenderness to palpation in the super-pubic area; no masses or organomegally; peripheral pulses reg., equal, intact; pelvic exam reveals pink vaginal mucosa with a moderate whitish-clear discharge; she is exceedingly tender to palpation and her uterus is enlarged. 

Urinalysis in the office: Cloudy amber yellow urine, Sp. Gr. 1.010, positive WBCs, nitrites, and leukoesterase; negative for RBCs, glucose, and ketones.

Urine Culture and Sensitivity:

Urine Culture Lab Results

CBC:

CBC Lab Results

I need this answere dthoroughly with rationales for each diagnosis and citations for each too.

Discussion Part Two:

What is the primary diagnosis for Kayla with rationale?

What is the differential diagnosis with rationale?

Plan for each primary diagnoses based on one current evidence-based journal article. Include the following:

Further diagnostic work-up not included above

Medications

Referrals

Conservative measures

Patient education

Follow-up plan