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Lyceum of The Philippines University Batangas

Capitol Site, Batangas City

CASE
STUDY OF
BREAST
CANCER
INTRODUCTION
Breast cancer is a cancer that starts in the cells of
the breast in women and men. Worldwide, breast
cancer is the second most common type of cancer
after lung cancer (10.4% of all cancer incidence,
both sexes counted) and the fifth most common
cause of cancer death. In 2005, breast cancer
caused 502,000 deaths worldwide (7% of cancer
deaths; almost 1% of all deaths).
Breast cancer also occurs in males. Incidences of
breast cancer in men are approximately 100 times
less common than in women, but men with breast
cancer are considered to have the same statistical
survival rates as women.
In this case study, I am eager enough
to know and understand better the
disease. It has been chosen, since it
is now fastly increasing in our
morbidity rates among diseases. It is
better for me to be educated with its
causative factors as well as the
prevention and management
whenever BREAST CANCER occurs.
OBJECTIVES

General Objective:
This study aims to
develop the knowledge,
skills and attitudes of the
student nurses through
effective utilization of
nursing process in dealing
with the course of patient
with BREAST CANCER.
Specific Objectives:
At the end of the study, the
student nurses will be able to:
1. Identify the patient’s profile, past
medical history, as well as the family
history, personal history, social history,
psychological history and the patient’s
history of present illness for further
understanding his condition.
2. Analyze the physical appearance of the
patient using Inspection, Palpation,
Percussion and Auscultation method
that may help in determining the
clinical manifestation presented by the
disease.
3.Identify, interpret and analyze the
laboratory and diagnostic
examination and its significant
findings to justify the presence of
the disease.
4.Identify and enumerate the
anatomical part of the body that is
involved and affected by the
disease and its respective
functions.
5.Explain the nature and identify the
causes and predisposing factors
that contribute to the development
of the disease.
6.Formulate Nursing Care Plan for
better delivery of care based on
the client’s needs and concerns.

7.Determine the effects of different


drugs that were administered to the
patient.

8.Note changes in the condition of


the patient and the degree of
development of his condition.

9.Enumerate all the references


used to make the case more
effectively and much clearer.
PATIENT’S PROFILE
NAME: Mrs. A
AGE: 39 years old
SEX: Female
DATE OF BIRTH: April 8, 1969

CIVIL STATUS: Married


ADDRESS: Pagaspas,
Tanauan
NATIONALITY: Filipino
RELIGION: Roman Catholic
DATE OF ADMISSION: December 6,
2008
PHYSICIAN: Dr.
Tenorio/Gonzales/Reyes
CLINICAL
APPRAISAL
A.Past Health History
According to Mrs. A she
has completed her
childhood immunization.
She has no allergy to any
foods, drugs and insect
bite. Mrs. A doesn’t have
any injury or accident in the
past. And it is her first time
that she was confined in the
hospital.
B.Family History
Mrs. A ‘s husband is a
construction worker they were gifted
with two children living in Nueva
Ecija. Her sister has a family history
of Breast Cancer.
C.Personal
History
Mrs. A has stopped working since her
right breast mass become enlarged.
She ignored the enlargement of her
right breast mass because of
deficient knowledge and financial
status. She has an abnormal
D. Social History

Mrs. A is living in a
Government housing area. Their
house is structured close to their
neighbors and her condition was
not a hindrance for her to mingle
or socialize with them.
E.Psychological History

It is a major stressor for Mrs. A


to be hospitalized for several weeks.
She has limited movement due to
her right breast mass that bleeds
every time she moves.
F. History of Present
Illness
Mrs. A was admitted on
December 6, 2008 with a chief
complaint of bleeding of her right
breast mass. And based on the
results of her physical exam the
doctor’s admitting impression was
PHYSICAL ASSESSMENT
General Survey
During the assessment for the general appearance, it
showed that she has a poor body coordination and is
considered abnormal because of the presence of
blood on the napkin over the right breast mass that
affects her posture and movement. She has a poor
body and oral hygiene due to self care deficit. Her
mood and manner is good, she is cooperative and has
willingness to participate in any medical procedure.
Vital Signs:
Temperature: 37C
Blood Pressure: 100/80mmhg
Pulse rate: 70 beats/min
Respiratory rate: 22 breaths/min
BODY METHOD FINDINGS ANALYSIS
PART
•Skin •Inspection •Dark •Normal

•not tender •Normal

•Absence of •Normal
edema
BODY PARTS METHOD FINDINGS ANALYSIS
•Skin •Palpation •Warm to touch •Normal
•Inspection •long and black with •Normal
normal distribution

•Hair •Absence of nodules


•Palpation •No dandruff •Normal
•Scalp
•Normal

•Symmetrically
•Head •Inspection aligned at the
midline.
•Normal
•Without lumps
•Palpation
•Normal
BODY PART METHOD FINDINGS ANALYSIS

•Nails •Inspection •Capillary •Normal


And refill every 3
palpation seconds

•Dirty, long •Normal


nails
BODY METHOD FINDINGS ANALYSIS
PARTS
•Face •Inspection •Facial features •Normal
& facial
movements are
symmetrical
•symmetrically
aligned with
•Neck •Inspection head at the •Normal
and center and
Palpation without bulging
masses

•Level shoulder

•shoulder •Normal
•Inspection
BODY PARTS METHOD FINDINGS ANALYSIS

•Thyroid Gland •Inspection •No enlargement •Normal


and of thyroid gland
Palpation

•Eyes
eyebrow •Symmetrically •Normal
•inspection aligned
•Hair evenly
distributed
•Normal
BODY PARTS METHOD FINDINGS ANALYSIS

•Eyes
Eyelashes •Inspection •Normal •Normal
distribution

Conjunctiva •Inspection Clear, moist •Normal


and smooth
underlying
structures are
clearly visible
sclera is white

Papillary •Inspection •Equally •Normal


Reaction reactive to light
BODY PART METHOD FINDINGS ANALYSIS

•Ear
Auricle •Inspection •Symmetrically •Normal
aligned

•Color of the auricle •Normal


is same as the face.

Ear canal •With Discharges •Abnormal,


impacted cerumen
blocking the view of
the external ear
canal, conductive
hearing loss.
•Pinna recoils after
being folded
•Palpation •Normal
BODY PART METHOD FINDINGS ANALYSIS
•Nose •Inspection •Symmetrically •Normal
aligned

•Uniform in •Normal
color

•Not tender •Normal


BODY PARTS METHOD FINDINGS ANALYSIS

•Mouth
Lips •Inspection •Dry w/ cracks •Abnormal. It
indicates
dehydration
•Abnormal. Due
Teeth •Inspection •Presence of
to oral hygiene
dental carries
practice.

•Normal
Tongue •Inspection •At the midline
•Abnormal due
•Dry w/ patches to dehydration
•Normal
•Palpation •Normal
•Moves Freely
•Not Tender
BODY METHOD FINDINGS ANALYSIS
PARTS
•Mouth
Uvula •Inspection •Position •Normal
centrally
Lymph •Palpation •Not palpable •Normal
nodes

•Chest and •Inspection and •Presence of •Abnormal due to


Lungs Auscultation cyst, open breast cancer.
wound (5cm)
and presence
of blood on the
right breast
•Normal heart
beat •Normal
BODY PART METHOD FINDINGS ANALYSIS
•Abdomen •Inspection •Symmetrically •Normal

•Auscultation •Normal bowel •Normal


sound

•Percussion •Normal bowel •Normal


sound

•Tenderness
•Palpation •Normal
BODY PARTS METHOD FINDINGS ANALYSIS
•Upper
Extremities
Hands •Inspection •Presence of •Abnormal. Fluids are
and IV (PNSS) regulated to replace
Palpation losses and aid to
immobilization of
secretion.

•Palpation •Normal
Pulse •Distal pulses
are palpable
BODY PARTS METHOD FINDINGS ANALYSIS

•Lower •Inspection •No Edema •Normal


Extremities and Palpation
SUMMARY OF PHYSICAL
ASSESSMENT
Mrs. A was admitted on December
06, 2008 and was diagnosed with
breast cancer (T4N1M0) stage IIIB.
The patient was assessed through
inspection, palpation, percussion and
auscultation for her physical
appearance that will serve as a
baseline
As Idata.
assessed the mouth, she has
dry lips tat indicates dehydration and
her teeth has yellow cavities due to
oral hygiene practice. By inspection,
the chest has presence of cyst, open
wound (5cm) and presence of blood on
DATE TAKEN: DECEMBER 07,2008

RESULT NORMAL VALUES ANALYSIS

1)Erythrocytes 3.80 X 10^12/ L F:3.6-5.0X1012 /L Normal

2)Hgb 100.6g/L F:120-140 g/L Decreased hgb level


are found in anemia
and may occur with
hemorrhage

3)Hct 0.32% F:0.36-0.48% Decrease hct values


indicates anemia in
which there is a
reduction in the PVC

4)Leukocytes 6.50 x10 9/L 4.5-10.5 x10 9/L Normal

5)Neutrophil 0.680% 1.2-6.6 x 10 9/L Neutrophenia

6)Eosinophil 0.018% 0-0.7 x 10 9/L Eosinophilia

7)Basophil 0.003% 0.02-0.05 x 10 9/L Basophenia


DATE TAKEN: DECEMBER 07,2008

RESULT NORMAL ANALYSIS


VALUES

8)Lymphocyte 3.80 0.214% 1.5-4.0 x 10 9/L Normal

9)Monocyte 0.040 x 10 9/L 0.1-0.5 x 10 9/L Normal

10)Thrombocyte 245x 10 9/L 150-400 x 10 9/L Normal

11)MCH 27.27 27-31 Normal

12)MCV 83.08 80-96 Normal

13)MCHC 0.33 0.32-0.36 Normal

14)Atypical 0.007 1.5-4.0 x 10 9/L Abnormal


Lymphocyte lymphocytes, can
be also associated
with viral infection
REMARK: Blood type (A+)
BLEED TIME: 1minute (Normal
value 1-3 minutes) -NORMAL
CLOTTING TIME: 4minutes
(Normal value 2-6 minutes)-
NORMAL
URINE ANALYSIS:

RESULT ANALYSIS
Color Yellow Normal
Characteristics Slightly turbid Presence of
pus,RBC/bacterial
cell
Specific gravity 1.020(1.015-1.025) Normal
Reaction 6.05 (4.5-8) Normal
Albumin Negative Normal
Sugar Negative Normal
Pus cells 3.5Hpf (0-4 Hpf) Normal
RBC To numerous to count Normal
Amorphous urates Moderate Normal
Epithelial cells Moderate Hematuria
LIVER ULTRASOUND Date
Taken:December 09, 2008

FINDINGS:

The liver is normal in size, configuration and


echo pattern with no facial mass, portal vein and
its tribataries are not dilated.

IMPRESSION: Normal Liver


Summary of Laboratory Result:

The laboratory exam of Mrs. A was


taken on December 07, 2008, and as I
analyzed the result of her hematology
exam I found out that her hemoglobin
and hematocrit level is abnormal that
indicates anemia and her atypical
lymphocyte is also abnormal that results
to viral infection.

The result of her liver ultrasound


was normal while her urine content has
shown presence of pus, RBC/ bacterial
cell.
ANATOMY AND PHYSIOLOGY

The breasts are composed of fatty


tissue that contains the glands responsible
for milk production in late pregnancy and
after childbirth. Within each breast, there
are about 15 to 25 lobes formed by groups
of lobules, the milk glands. Each lobule is
composed of grape-like clusters of acini
(also called alveoli), the hollow sacs that
make and hold breast milk.
The lobules are arranged around
ducts that funnel milk to the nipples.
About 15 to 20 ducts come together near
the areola (dark, circular area around the
nipple) to form ampullae - cavities that
store the milk before it reaches the nipple
surface. Montgomery's glands are small oil
glands that are located around each
areola. They release a lubricant that
protects the nipples during nursing.
The breasts lie over the pectoralis
muscles of the chest. Each breast is
composed of 12 to 20 lobes of
glandular tissue separated by
connective tissue. The lobes are held in
place by suspensory ligaments
connected both to the skin and to the
underlying fascia. The milk gland ducts
in each lobe join to form a larger duct
that terminates in rounded by fat that
determines the size of the breasts.
Lymphatic drainage of the breasts is
primarily to the axillary nodes but
some lymph also drains toward
The breasts are associated
functionally with the reproductive
system as an organ for milk
production in the postpartum
woman. The female sex hormones
influence the development of the
breasts and the production of milk.
The breast is made up of the
secretory glandular tissue and
surrounding adipose tissue.
The glandular tissue comprises
between 15 and 20 lobes with
varying numbers of ducts and
lobules surrounded by connective
tissue. Each lobe connects to a
lactiferous duct, several of which
converge to form a lactiferous sinus
or milk chamber. These sinuses
empty into the nipple where there
are a number of duct openings.
The nipple is surrounded by a
pigmented area, the areola, which is
lubricated by secretions from the
sebaceous glands.
Beneath the tissues of the
breast lie the muscles of the chest wall
and between the two is a layer of
connective tissue known as the fascia.
Two layers of fibrous
ligaments (Cooper’s ligaments)
support the mammary gland. These
arise from stromal elements in the
gland and insert into the skin and
pectoral fascia, holding the breast
against the chest. As these ligaments
stretch, in obesity, old age or following
The breast is composed of:
•milk glands (lobules) that produce milk
•ducts that transport milk from the milk glands
(lobules) to the nipple
•nipple
•areola (pink or brown pigmented region
surrounding the nipple)
•connective (fibrous) tissue that surrounds the
lobules and ducts
•fat
NON MODIFIABLE RISK
BREAST CANCER
MODIFIABLE RISK FACTOR
FACTOR

GENETICS SOCIO ECONOMIC STATUS


•Age
•Family history of Breast Cancer

Two Types of non Invasive Breast


Cancer

LAB RESULT
NEUTROPHILS- Decreased •Ductal Carcinoma
Hgb- Decreased •Lobular Carcinoma
Hct- Decreased
ATYPICAL LYMPHOCYTE-
decreased
Stage 0—non-invasive
carcinomas (LCIS or DCIS). 
Cancer cells have not invaded
the surrounding breast tissue.

Stage IIA – T 2-5 cm, N Stage I - Tumor (T) does not


Stage IIB – T > 5 cm, N
negative, or T <2 cm and N involve axillary lymph nodes
negative, or T 2-5 cm and
positive. (N).
N positive (< 4 axillary
nodes)

Stage IIIA – T > 5 cm, N


positive, or T 2-5 cm with 4
or more axillary nodes

Stage IIIB – T has


penetrated chest wall or
skin, and may have spread
to < 10 axillary N)
SUMMARY OF PATHOPHYSIOLOGY
Breast cancer is either invasive or noninvasive (often
referred to as in situ).  There are two types of noninvasive
breast cancers: ductal carcinoma in situ (DCIS) and lobular
carcinoma in situ  (LCIS).  These two types of noninvasive
breast cancers do not invade the basement membrane of the
breast .  As their names suggest ductal carcinoma in situ
cancer cells are found in the lining of the duct whereas
lobular carcinoma in situ cancer cells are found in the lobules
(see Anatomy section for a detailed description of the ductals
and lobules of the breast). Each of the four types of breast
cancer has four stages that relate to the severity of the
cancer. The following describes the types and stages of
breast cancer.
Stage 0 - Carcinoma in situ (DCIS) Stage I - Tumor (T) does
not involve axillary lymph nodes (N). Stage IIA – T 2-5 cm, N
negative, or T <2 cm and N positive. Stage IIB – T > 5 cm, N
negative, or T 2-5 cm and N positive (< 4 axillary nodes).
Nursing Care Plan
ASSESSMENT
S>“Di ko na masyado nararamdaman ang kirot sa
suso ko”.
O> appears relaxed
 slow movement
Limited mobility
NURSING DIAGNOSIS SCIENTIFIC EXPLANATION

Readiness for enhanced A pattern of ease, relief


comfort related to and transcendence in
participation in desirable physical, psycho spiritual,
and realistic health – environmental and social
seeking behaviors. dimensions that can be
strengthened.
PLANNING
After 3 hours of nursing intervention, the
client will:

Verbalize sense of comfort or contentment.


Demonstrate behaviors of optional level of
ease.
INTERVENTION RATIONALE

Provided therapeutic touch Helps promote relaxation


to promote ease. and refocus attention

(Nurse’s Pocket Guide, 11th edition,


Marilynn E. Doenges, p163)
INTERVENTION RATIONALE

Assisted client to use and Helps make best use of


modify medication regimen. pharmacologic pain
management.

(Nurse’s Pocket Guide, 11th edition,


Marilynn E. Doenges, p163)
INTERVENTION RATIONALE

Encouraged adequate rest Prevents fatigue.


periods.
(Nurse’s Pocket Guide, 11th edition,
Marilynn E. Doenges, p164)
INTERVENTION RATIONALE

Encouraged client to do Enhances self – esteem and


whatever possible. independence.

(Nurse’s Pocket Guide, 11th edition,


Marilynn E. Doenges, p164)
EVALUATION
The client:

Verbalized sense of comfort/contentment


Demonstrate behaviors of optional level of
ease.
as evidence by:
•“Hindi ko na namalayan na masakit o
kumikirot ang suso ko dahil sa
pagkukuwentuhan namin”.
NURSING CARE PLAN

ASSESSMENT
S> “Hindi ako masyadong makagalaw dahil baka
tumagas na naman ang dugo”.

O> impaired ability to turn side to side, move from


supine to sitting, “scoot” or reposition self in bed
Less movement
Presence blood on the napkin in the right breast
NURSING DIAGNOSIS SCIENTIFIC EXPLANATION

Impaired bed mobility related Limitation in independent,


top bleeding of right breast purposeful physical movement
of the body or of one or more
mass.
extremities
PLANNING

After 1-2 hours of nursing interventions the


client will verbalize willingness to /and
participate in repositioning program.
INTERVENTION RATIONALE

Evaluated patient’s ability Identifies impairments


function and and allows for identification
Injury of appropriate intervention

Assessed patient for Provides a baseline on


degree of immobility which to base intervention,
  patient may only require
minimal assistance or be
completely dependent on
caregiver’s for all body
needs
INTERVENTION RATIONALE

Instructed patient or family in Helps patient to regain


repositioning for good body some control and allows
alignment using appropriate family some involvement in
support reconditioning program
EVALUATION
The client verbalized willingness to
/and participated in repositioning
program.
Drug Study
NAME OF DRUG CLASSIFICATION AND ACTION

GENERIC NAME:
Cephradine Antibiotic

BRAND NAME: Chemical Effect: Inhibits – cell wall


Velosef synthesis promoting instability; usually
bactericidal.
Route and Dosage:
1g/IV q8 Therapeutic Effect: Hinders or kill
bacteria
INDICATION CONTRAINDICATION
Often used in clients Contraindicated to patients
allergic to penicillin hypertensive to drugs, other
cephalosporins, or beta – lactam
Gram positive antibiotics.
organisms and
moderate activity Use cautiously in patents with
against gram negative renaldysfunction or history of sensitivity
organisms. to penicillin.
ADVERSE NURSING RESPONSIBILITY
REACTION
CNS: dizziness, fatigue, Assess patient’s infection before
headache, insomnia, therapy and regularly thereafter.
malaise, nervousness, Before giving first dose, obtain
somnolence. specimen for culture and sensitivity test.
GI: abdominal pain, Before giving first dose, ask patient
diarrhea, dyspepsia, about previous reactions to
flatulence, loose stools, cephalosporin or penicillin.
nausea, vomiting. Be alert of adverse reactions and drug
GU: genital candidiasis, interaction
genital pruritus, vaginitis.
SKIN: pruritus, rash.
MONITORING PARAMETERS

May increase BUN, creatinine, ALT, AST,


alkaline phosphate, bilirubin, GGT, and LDH
levels

May increase eosinophil count, may


decrease platelet and WBC counts.

May cause false – positive results in urine


glucose test that use copper sulfate.
NAME OF DRUG CLASSIFICATION AND
ACTION
GENERIC NAME:
Metronidazole Anti-infective
BRAND NAME: Flagyl
IV Increases permeability of the fungal
cell membrane causing cell death.
Route: IV

Dosage: 500mg/ IVq6


INDICATION CONTRAINDICATION
Fungal Infections Hyper sensitivity to any anti-fungal,
liver failure, pregnancy, lactation.
ADVERSE NURSING RESPONSIBILITY
REACTION
Headache, dizziness,
nausea, vomiting, pruritus,Instruct client to take medication with
irritation with topical food.
application.
Review importance of taking the full
course of medication.

Discuss hygiene measures to control


reinfection.
MONITORING PARAMETERS

May decrease in Blood Levels with


rifampin.

May increase risk of toxicity of


cyclosporine with anti-fungals.
NAME OF DRUG CLASSIFICATION AND
ACTION
GENERIC NAME:
Ketorolac Anti inflammatory

BRAND NAME: Inhibits prostaglandin synthesis;


Toradol resulting in ANALGESIC, anti-
inflammatory and, anti pyretic
Route: IV activities.

Dosage: 300mg q8
INDICATION CONTRAINDICATION

To reduce fever and Allergy to salicylates or NSAIDs,


inflammatory process. renal or hepatic disease, asthma, peptic
ulcer, bleeding disorders.
Musculoskeletal
disorders. Caution with elderly.
ADVERSE NURSING RESPONSIBILITY
REACTION
Bone marrow
depression, increased Instruct client to take with
GI distress, renal meals.
toxicity, tinnitus and
hepatotoxicity.
Avoid alcohol and consult with
provider about other meds.

Advise not to take aspirin or


acetaminophen when taking an
NSAID.
MONITORING PARAMETERS

May increase the risk of bleeding with oral


anticoagulants.

May increase effects of lithium.

May decrease effect of loop diuretics.


PROGNOSIS

Mrs. A was admitted in December


06, 2008 at Batangas Regional Hospital
with a chief complaint of bleeding of her
right breast mass under the care of Dr.
Tenorio/Gonzales/Reyes. The admitting
impression was Breast Cancer (T4N1M0)
stage Some
IIIB. laboratory exams like
hematology, urinalysis, blood transfusion,
liver ultra sound were done and given
medication to the patient to improve
client’s condition.
But because of certain reason like
CP evaluation Mrs. A was not yet able to
have biopsy and operation to be done.
DISCHARGE PLANNING

M- Advised to continue regular


intake of medication prescribed
by the physician.

E-Taught the patient about the


appropriate passive and active
exercises of the hand, arm and
shoulder of the affected side.
T- Advised the patient for
proper boy positioning to
promote comfort, such as
semi-Fowler’s position and
elevation of the arm of the
affected side.
H- Advised the patient to
provide good personal hygiene
of the client. of dust.
Encouraged protection and the
avoidance of anything that can
be break through the skin
barrier to impose stress on the
arm and the shoulder.
O- Encouraged to have a follow-
up check-up after one week to
Dr. Tenorio/Gonzales

D- Advised the patient to


provide foods rich in fiber and
calcium such as milk and
blended banana to the patient.
S- Advised whole family to keep
their faith in GOD and never
forget to ask guidance and
support from our Lord.
ACKNOWLEDGEMENT
Doing things alone is an impossible
task. That’s why I wish to extend my
deepest and heartfelt gratitude to those who
patiently help me in fulfilling this task and to
whom I owe this success of my endeavor.
First and foremost, to our Almighty
God, for the knowledge and wisdom he
showered upon me; for His continuing
guidance, for giving me the strength to
overcome my trials and for every little thing
He’d done fordear
me. parents, for assisting me
To my
in my needs, financially and emotionally; for
being there whenever I need them, for
staying on my side through ups and downs
and most of all for making me responsible
individual.
To my Clinical Instructor, Dra.
Annabelle Iturralde for sharing her
knowledge to the best of her ability; for
guiding me the right way, I will treasure all
the learnings that she had taught me.
To Batangas Regional Hospital who
trust us and permitted me to handle my
patient.

To my members in the group for


their cooperation and for giving me extra
information even in the smallest thing that
they know. THANK YOU VERY MUCH
AND GOD BLESS US ALL!!!
BIBLIOGRAPHY

•Nursing Care Plan,7th edition, Doenges, et.al

•Medical-surgical nursing, Smeltzer,et al.

•Delmar’s Manual of Laboratory and Diagnostic Test, Rick


Daniels

•Health Assesment & Physical Examination, Estes

•Medical-Surgical Nursing, Brunner and Suddharts,


Smeltzer,vol.1 & 2
•Laboratory and Diagnostic tests with nursing
implecations 7th edition, Joyce Lefever kee.

•Nursing 2008 Drug handbook, 28th edition, Wolters


kluwer et, al;

•Nurse’s Pocket Guide 11th edition, Doenges,et.al


Presented by:Kristien Grace C.
Javina
BSN III-5 C

Presented to:Dra.Annabelle
Iturralde
Clinical Instructor

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