STU Female Genitourinary and Musculoskeletal Discussion – Description
Chief Complaint
(CC) “I have a tumor on my left breast”
History of Present Illness (HPI)A 55-year-old African American social worker presents to your clinic with a finding of a lump in her left breast while in the shower this past week.
Drug HxI took birth control pills for 10 years, starting when I was 20 I am not on hormone replacement
Family HxMy grandmother had breast cancer when she was 76 years old
Subjective
Denies any fever or chills. No changes in vision or hearing, no difficulty chewing or swallowing. Supple neck, states that she does self-breast-exams on occasion. Menopause at 52
No skin changes or nipple discharge from the left breast
Objective Data VStemperature 98.6°F; respiratory rate (RR) 16; heart rate (HR) 80, regular; blood pressure (BP) 130/84; height: 5?8?; weight 160 lbs; body mass index (BMI) 24
Generalwell developed, nourished, healthy-appearing female
HEENTAtraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.
Lungsclear to auscultation
Cardregular rate and rhythm (RRR)
BreastExamined in sitting and supine positions. In sitting position, no evidence of skin changes, right breast is slightly larger than the left, symmetrical movement with the arms above the head and at the side and with flexion of the pectoral muscles; 5-mm nonmobile, non-tender, firm mass felt at 10 o’clock position, 5 cm from the areola. Right breast without dominant masses or tenderness. Nipples without inversion or evidence of nipple discharge. Breast mass is palpated in the supine position in the same manner as in the sitting positionLymphnegative axillary, infraclavicular, and supraclavicular lymphadenopathy
Abdnormoactive bowel sounds x 4;
GUBladder is non-distended.
Integumentgood skin turgor noted, moist mucous membranes
MSMuscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation.
NeuroNo obvious deformities, CN grossly intact II-XII
Once you received your case number, answer the following questions:
What other subjective data would you obtain?
What other objective findings would you look for?
What diagnostic exams do you want to order?
Name 3 differential diagnoses based on this patient presenting symptoms?
Give rationales for your each differential diagnosis.
What teachings will you provide?
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