female genitourinary, & musculoskeletal | Nursing homework help

Case 1

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 Hx

I took birth control pills for 10 years, starting when I was 20 l am not on hormone replacement

Family Hx

My 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

 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

temperature: 98.2°F, respiratory rate 16, heart rate 90, blood pressure 120/60 
O2 saturation 98% 

 General

well developed, nourished, healthy-appearing female

well-developed healthy 35-year-old male; no gross deformities

 HEENT

Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous. 

Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries. 

Lungs

clear to auscultation 

CTA AP&L

Card

regular rate and rhythm (RRR)

S1S2 without rub or gallop

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

• INSPECTION: no dimpling or abnormalities noted upon inspection

• PALPATION: Left breast – no abnormalities noted. Right breast – denies tenderness, pain, no abnormalities noted.

Lymph

negative axillary, infraclavicular, and supraclavicular lymphadenopathy

no bruising, fever, or swelling noted, no acute bleeding or trauma to skin.

Abd

normoactive bowel sounds x 4; 

benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.

GU

Bladder is non-distended.

Bladder is non-distended.

Integument

good skin turgor noted, moist mucous membranes

intact without lesions masses or rashes.

MS

Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation.

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. 

Neuro

No obvious deformities, CN grossly intact II-XII

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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