This week, your case for review is about a radical mastectomy. Using the South University Online Library or the Internet, research about the healthcare insurance, facility, and provider practices involved in the care of patients suffering from radical mastectomy.

Based on your readings and research, answer the following:

Discuss the process by which the patient in the case study is referred through the healthcare system from primary care to tertiary care and rehabilitation. What parts of this process works well and what can been improved?
What is the significance of the patient’s payer in determining her care?
Do you feel that the patient’s referral from primary care to specialty care is handled appropriately? If no, why not?
What is the role of Telemedicine in this week’s case study?
In your discussion, be sure to use the new vocabulary that is relevant to the topic.

CASE STUDY
Mrs. Nancy Stritmatter is a thirty-nine-year-old professional chef in Cincinnati, Ohio. Nancy and her husband Roy own and operate a successful restaurant and catering service there. They have three sons of ages eleven, thirteen, and sixteen.

For years now, Nancy has been performing a monthly breast exam as instructed by her nurse practitioner, Jana Cook, Advanced Registered Nurse Practitioner (ARNP) Notes, at the Silverton Clinic near her home. Nancy is officially a patient of Dr. David Pederson at the clinic, but she has always been much more comfortable with Jana, especially for “female” matters. Nancy takes her monthly breast exam ritual seriously. Her mother and one of her aunts died of late-diagnosed metastasizing breast cancer.

On conducting her breast self-exam, Nancy notices one small area in the upper, outer region of her right breast that seems a little different. She can’t really call it a “lump,” but something feels different there. She also notices a tiny amount of dimpling of the skin over that area. Nancy immediately places a call to Jana Cook at the clinic. Notes

Primary Care

Jana wants Nancy to come to the clinic the same day, but Nancy has a large Rotary awards luncheon that day. As Nancy works all morning getting ready for the banquet, and then works all afternoon on the cleanup, she can think of nothing else. She also struggles back and forth with whether she should tell Roy anything about this just yet. She decides not to.

Roy does notice that Nancy is a little quiet, but Nancy explains that she is just tired. Tuesday night is sleepless for Nancy. On Wednesday morning, Jana calls Nancy’s home at 7:30 a.m. Dave, who takes the call, assumes it is about catering the Medical Staff Golf Tournament dinner which Jana organizes each year.

Physical Exam

At the clinic, Jana does a thorough physical exam, including a breast exam. She is looking for any of the characteristics of breast cancer, which include:


Lumps or thickening in or near the breast, or in the underarm area

Nipple discharge or inverted nipple

Redness or changes in the skin or contour of the breast, areola

Nipple ridges or pitting of the breast in which the skin looks like the skin of an orange


Jana finds the area, which Nancy describes, and she is concerned. There is a definable density, though very small, in the right breast, on the upper, outer quadrant. There is some pitting of the skin over this area. There is no enlargement of the lymph nodes in the right axilla.

Jana explains, “Nancy, the fact that we are noticing density in the outer, upper part of the breast means that we really need to work on this right away. Findings in this area of the breast are more likely to be more trouble than findings in some other areas. When I couple that with your family history it means that you need to get a mammogram done today.”

There is a mobile mammography unit that comes to the clinic once a month. But Jana doesn’t want to wait till the next scheduled visit, which is on Friday. She recommends that Nancy go to the Cincinnati Breast Care Center because it is a provider for Nancy’s insurer. Nancy has Blue Cross/Blue Shield “Blue Select” insurance through the small business association. A medical Helpant at the clinic gets Nancy an appointment the same day at 5:45 p.m. Notes

Meanwhile, Jana quickly confers with Dr. David Pederson, her supervising physician, who concurs with her plan of care and signs off on the chart.

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