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iHuman Rachel Hardy :Breast Disorder Case Study correct preview as per marking scheme with actual answers
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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
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
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: