Assessment
38 year old with history of breast cancer with postmastectomy pain, limited response to opioid pain medications, and negative impact on function.
History of Present Illness
Ms. Jackson is a 38-year-old, African American nurse who completed treatment for triple negative breast cancer 5 months ago. She opted for bilateral mastectomy, radiation, and chemotherapy.
Her treatment history is significant for very poor pain control following her mastectomies and her TRAM flap reconstruction, which were performed 3 months apart. Ms. Jackson describes her post-operative experience as “horrific and isolating.”
She rates her global pain as a 7 on a 0 to 10 scale, and notes that the pain is both constant and “unrelenting.” She has persistent moderate to severe pain that she describes as a tight “band” around her chest.
Additional moderate pain sensations, she states, feel like “burning or tingling” in her hands, suggesting a neuropathic pain component, which have been gradually improving since completion of the chemotherapy. The patient is frustrated that she still experiences pain, states “it’s ruining my life, I don’t think it will get better, and I worry that my family and friends don’t care about me anymore.”
Past Medical History
Intraductal carcinoma of the breast
Past Surgical History
Bilateral mastectomy with TRAM flap reconstruction
Current Medications
- Hydromorphone 4mg every 4 hours as needed
- Sustained release oxycodone 60 mg every 12 hours
- Gabapentin 300 mg every 8 hours
- Multivitamin
- Aspirin
Allergies
None known
Family History
Ms. Jackon’s mother and sister both died of breast cancer before their 45th birthdays. Ms Jackson recalls their illnesses and deaths vividly, and notes that they had excruciating pain. Ms Jackson has one older brother who has both hypertension and diabetes mellitus. He is an alcoholic. There is no other illness in the family.
Social History:
Mrs. Jackson is divorced, and has an amicable relationship with her ex-husband. She has two adult daughters, who live nearby and are very engaged in her life.
Psychiatric History
Mrs. Jackson states she was probably depressed at the time of her divorce, but did not receive any treatment for depression at that time.
Substance Abuse History
Mrs. Jackson has no history of substance abuse
Review of Systems
As above.
Physical Exam
Vital Signs
Temperature 97.2, Blood Pressure 152/88, Heart Rate 96, oxygen saturation 96% on room air
General Appearance
Well developed woman, no distress
Head, Ears, Eyes, Nose, Throat and Mouth Exam
Normocephalic, sclera anicteric, conjunctivae clear, oral mucosa moist and pink.
Neck
Normal range of motion.
Lungs
Clear.
Heart
Tachycardic, regular rhythm, no murmurs.
Chest
Reconstructed breast mounds bilaterally, scars well healed, tenderness to superfical touch bilateral axilla.
Abdomen
Soft, palpable liver tip, no masses, no tenderness to palpation, low horizontal well healed scar from TRAM flap.
Extremities
No cyanosis, clubbing or edema.
Skin
No rashes.
Musculoskeletal
Strength 5/5 upper and lower extremities.
Neurological
Alert and oriented, normal gait, cranial nerves intact.
