iHuman Rachel Hardy :Breast Disorder Case Study correct preview as per marking scheme, Exams of Nursing

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iHuman Rachel Hardy :Breast

Disorder Case Study

correct preview as per marking scheme

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I Human Rachel Hardy; Breast Disorder

case study

CC: “I can feel two lumps in my breast.” HPI: R.H. is a 42 year old female who presents with a chief complaint of two right-sided breast lumps that were self-detected. Patient's mother was diagnosed with breast CA at age 48, currently still living. Patient has a breast biopsy 3 years ago which showed atypical ductal hyperplasia. Patient denies any breast pain, discharge, bleeding, skin changes, palpable lymph nodes, or fevers. She reports a recent 11lb weight loss over the past 3 months due to unknown cause. Physical exam shows 2 palpable breast masses, one 2.5cm mass in the upper quadrant of the right breast, and another 2cm mass in the right breast. A right axillary lymph node that is hard and mobile is also palpable. Past Medical History

• Chronic idiopathic pancreatitis
• Hypothyroidism
• Atypical ductal hyperplasia Past Surgical History Pancreas sx last year Social History
• Tobacco use: 1 - pack year history
• Drug use: denies
• Alcohol use: 2 glasses of wine per day starting at age 18; quit 6 years ago
• Marital status: never married
• Current/previous occupation: disabled due to chronic pancreatitis
• Sexual orientation: female
• Sexually active: not sexually active for past 12 years
• Living situation: currently resides at home with 2 children Family History Mom- alive, breast CA at 48 Dad – alive, healthy Allergies No known drug allergies

HPI: R.H. is a 42 year old female who presents with a chief complaint of two right-sided breast lumps that were self-detected. Patient's mother was diagnosed with breast CA at age 48, currently still living. Patient has a breast biopsy 3 years ago which showed atypical ductal hyperplasia. Patient denies any breast pain, discharge, bleeding, skin changes, palpable lymph nodes, or fevers. She reports a recent 11lb weight loss over the past 3 months due to unknown cause. Physical exam shows 2 palpable breast masses, one 2.5cm mass in the upper quadrant of the right breast, and another 2cm mass in the right breast. A right axillary lymph node that is hard and mobile is also palpable. Past Medical History

• Chronic idiopathic pancreatitis
• Hypothyroidism
• Atypical ductal hyperplasia Past Surgical History Pancreas sx last year Social History
• Tobacco use: 1 - pack year history
• Drug use: denies
• Alcohol use: 2 glasses of wine per day starting at age 18; quit 6 years ago
• Marital status: never married
• Current/previous occupation: disabled due to chronic pancreatitis
• Sexual orientation: female
• Sexually active: not sexually active for past 12 years
• Living situation: currently resides at home with 2 children Family History Mom- alive, breast CA at 48 Dad – alive, healthy Allergies No known drug allergies Active Medications Levothyroxine 25 mcg Q AM Pancrealipase 15000 units 2 tab before each meal Oxycodone 5mg 1 tab PRN Q4 pain Amitriptyline 25mg 1 PO Q AM ROS:

General: Patient denies fevers, weight gain or loss, loss of appetite, night sweats, fatigue, or changes in sleeping. HEENT: Denies double or blurred vision, photophobia, discharge from eyes, or vision loss. Denies any abnormal nasal discharge, pain, or epistaxis. Denies hearing loss or tinnitus. CV: Denies any chest pains, palpitations or racing heart, bounding pulses, or edema. Respiratory: Denies any SOB, difficulty breathing, wheezes, or pain with inhalation/exhalation. GI: Denies any abdominal pain, nausea, vomiting, diarrhea, constipation, melena, or hematemesis. GU: Denies dysuria, frequency, hematuria, pain, or discharge. MS: Denies any new joint pains or swelling. Denies muscle pains, cramps, or weakness. Skin: Admits to two palpable right sided breast lumps. Denies any rashes or petechia, discharge, or abnormal pruritus. Denies any new skin lesions, or hair loss or increase. Neurologic: Denies any double vision, problems with walking or balance, weakness, or fainting. Psych: Denies memory loss, depression, agitation, suicidal thoughts, anxiety, mood swings, or hallucinations. Endocrine: Denies excessive thirst or urination, heat or cold intolerance, frequent hunger/urination/thirst, or changes in sex drive. Extremities: Denies pain or swelling, denies tingling or numbness to extremities. Allergic/Immunologic: Denies seasonal allergies, hay fever symptoms, itching, or frequent infections. Vital Signs: T: 98.4F PO P: 72 bpm BP: 116/ RR: 16 bpm O2: 98% RA Height: 5’ Weight: 149 lbs Physical Exam:

• GENERAL: A pleasant Caucasian white female, alert and responsive, and appears in no acute distress.
• INTEG: Skin appears warm, and normal in color and texture .No rash, pallor, or icterus noted.
• LYMPH: Two palpable breast masses, one 2.5cm mass in the upper quadrant of the right breast, and another 2cm mass in the right breast. A right axillary lymph node that is hard and mobile is also palpable.
• HEENT: Head Normocephalic, atraumatic. PERRLA, EOMI noted. Ears clear with normal tympanic membranes. Mucous membranes intact. Neck is supple without any masses or adenopathy.