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Case 1
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Chief
Complaint
(CC)
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“I have a tumor on my left breast”
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History of
Present Illness
(HPI)
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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.
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Drug Hx
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I took birth control pills for 10 years, starting when I was 20 l am not on hormone replacement
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Family Hx
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My grandmother had breast cancer when she was 76 years old
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Subjective
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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
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Objective Data
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VS
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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
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temperature: 98.2°F, respiratory rate 16, heart rate 90, blood pressure 120/60
O2 saturation 98%
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General
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well developed, nourished, healthy-appearing female
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well-developed healthy 35-year-old male; no gross deformities
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HEENT
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Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.
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Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries.
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Lungs
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clear to auscultation
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CTA AP&L
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Card
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regular rate and rhythm (RRR)
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S1S2 without rub or gallop
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Breast
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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
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• INSPECTION: no dimpling or abnormalities noted upon inspection
• PALPATION: Left breast – no abnormalities noted. Right breast – denies tenderness, pain, no abnormalities noted.
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Lymph
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negative axillary, infraclavicular, and supraclavicular lymphadenopathy
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no bruising, fever, or swelling noted, no acute bleeding or trauma to skin.
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Abd
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normoactive bowel sounds x 4;
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benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.
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GU
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Bladder is non-distended.
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Bladder is non-distended.
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Integument
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good skin turgor noted, moist mucous membranes
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intact without lesions masses or rashes.
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MS
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Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation.
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No obvious deformities, masses, or discoloration. Palpable pain noted at the right lower lumbar region. No palpable spasms. ROM limited to forward bending 10 inches from floor; able to bend side to side but had difficulty twisting and going into extension.
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Neuro
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No obvious deformities, CN grossly intact II-XII
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DTRs 2+ lower sensory neurology intact to light touch and patient able to toe and heel walk. Gait was stable and no limping noted.
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