Chief Complaint
(CC)
Paragraph
“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 Hx
I took birth control pills for 10 years, starting when I was 20 I am not on hormone replacement
Family Hx
My grandmother had breast cancer when she was 76 years old
Denies any fever or chills. No changes in vision or hearing, no difficulty chewing or swallowing. Supple neck, states
Subjective
that she does self-breast exams on occasion. Menopause at 52
No skin changes or nipple discharge from the left breast
VS
temperature 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
General
HEENT
well developed, nourished, healthy-appearing female
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.
Lungs
clear to auscultation
Card
regular rate and rhythm (RRR)
Breast
Examined 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 position
Lymph
negative axillary, infraclavicular, and supraclavicular lymphadenopathy
Abc
normoactive bowel sounds x 4:
GU
Bladder is non-distended.
Integument
good skin turgor noted, moist mucous membranes
MS
Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation.
Neuro
No obvious deformities, CN grossly intact II-XII
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?
Your initial post should be at least 500 words, formatted, and cited in current APA style with support from at least 2 academic sources.
Chief Complaint
(CC)
Paragraph
“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 Hx
I took birth control pills for 10 years, starting when I was 20 I am not on hormone replacement
Family Hx
My grandmother had breast cancer when she was 76 years old
Denies any fever or chills. No changes in vision or hearing, no difficulty chewing or swallowing. Supple neck, states
Subjective
that she does self-breast exams on occasion. Menopause at 52
No skin changes or nipple discharge from the left breast
VS
temperature 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
General
HEENT
well developed, nourished, healthy-appearing female
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.
Lungs
clear to auscultation
Card
regular rate and rhythm (RRR)
Breast
Examined 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 position
Lymph
negative axillary, infraclavicular, and supraclavicular lymphadenopathy
Abc
normoactive bowel sounds x 4:
GU
Bladder is non-distended.
Integument
good skin turgor noted, moist mucous membranes
MS
Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation.
Neuro
No obvious deformities, CN grossly intact II-XII
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?
Your initial post should be at least 500 words, formatted, and cited in current APA style with support from at least 2 academic sources.
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