NRNP 6568 Week 9 Assignment; Diagnosing, and Treating Special Populations.

Galactorrhea Case Study Student Name NRNP- 6568 Synthesis in Advanced Nursing Practice Care of Patients in Family Care Settings Walden University Dr. Jaffe Date Submitted Galactorrhea Case Study Focused SOAP Note Patient Information: M.S., 28, F, Caucasian S. CC: Nipple drainage HPI: This 28 y/o Caucasian female presents with c/o nipple drainage. Patient reports onset of bilateral nipple discharge in the last 3-4 months. Describes discharge as milky and occurring on the left side more than the right and is daily. Patient admits discharge does soak through her bra but does not leak through her outer clothing. Denies odor to discharge and denies erythema, tenderness or lumps to breasts. Patient expresses concern with having cancer. Patient reports associated symptoms of fatigue, constipation and changes in menses. Patient reports concern with menstrual periods recently becoming light when they have always been moderately heavy. Patient states onset of menses at age 13 and lasts about 5-7 days with heavy bleeding and moderate cramping for the first 3-4 days. Patient admits to use of 8-10 pads each day during the first 3-4 days of her periods. LMP 6/28/21. Patient reports increased fatigue over last 3-4 months. Patient does admit has battled with fatigue her whole life and has been told she does become anemic during her menstrual cycles and has been instructed to take iron tablets but she refuses this because it upset her stomach. Patient reports having regular stools at least once other day, with stools being soft and formed; however, she reports recent decrease in stools. Reports pattern has changed to a stool about once a week, but remains soft, formed and easy to pass. Location: Bilateral breasts Onset: 3-4 months Character: Milky Associated signs and symptoms: Light periods, fatigue and constipation Timing: daily Exacerbating/relieving factors: Compression or stimulation of the breasts increases discharge. Nothing relieves the discharge. Severity: 0/10 Current Medications: No prescription medications. No over-the-counter medications. No vitamins or herbals. Allergies: No known medication, environmental, food, or latex allergies. PMHx: Received all immunizations as a child. Influenza vaccine 09/2020. Moderna COVID-19 vaccine #1- 4/21/2021, #2- 5/19/21. Patient reports has never been diagnosed with COVID but has been exposed. No hospitalizations, injuries or trauma. No blood transfusions. Soc & Substance Hx: M.S. is single with no children. She is the only child to her parents who are still married and have been for 25 years. M.S. lives is an elementary school teacher in a small metropolitan in Missouri. Her parents reside in a neighboring community about 2 hours away. She denies tobacco use or vaping, no recent alcohol or illicit drug use. Does admit to drinking beer during college and has experimented with marijuana while in high school, but did not like the effects so she has not used it since. Drinks caffeine consisting primarily of Starbucks coffee, daily. Admits to not having hearing checked since she was in elementary school. Does get routine vision and dental exams. Last vision exam was a year ago, needed corrective lens, though she