unit 7 journal

Name:

Eileen Turner

 Pt. Encounter Number: 3

Date: 2/16/23

Age: 47

Sex: Female

SUBJECTIVE

CC: 

“Left breast lump”

·
HPI: 
47 y/o female G0P0 presents to the office with 5 week history of a lump in the left breast. Pt reports she initially detected the lump during her monthly SBE. She waited until her next cycle to examine again, and the lump persisted. The lump is located in the upper outer corner of the breast. She states that nothing makes it better or worse, and she has not had any treatment up until this point. Denies pain, nipple discharge or recent trauma. No other associated symptoms. Last mammogram 18 months ago was normal. She has been prescribed COC for 15 years for irregular periods. Family history of breast cancer- pts mother deceased age 49 as a result. She is seeking additional testing and work up.

Medications:
Levonorgestrel/Ethinyl Estadiol 0.15 mg/0.30mg orally daily for metrorrhagia, HCTZ 25mg daily in AM for HTN

Allergies:
NKA

Medication Intolerances:
none reported

Past Medical History:

HTN, controlled on HCTZ x 1 year

Metrorrhagia controlled on COC

Hospitalizations/Surgeries

Tonsillectomy as a child

Preventative Health:

Immunizations up to date

Screening mammogram 2 years ago BI-RADS Category 2-benign findings, calcifications noted bilaterally. Compliant with meds but does not regularly monitor her blood pressure.

Family History

Mother: deceased age 49 breast cancer

Father: HTN

No siblings

Social History

She completed her PhD and is currently employed as an elementary school principal. She lives alone, is not currently in a relationship and has no children. Pt reports she feels safe in her home in a gated community with neighbors whom she is friendly with. Denies tobacco, alcohol or recreational drug use.

ROS Student to ask each of these questions to the patient: “Have you had any…..”

General

Overweight but denies weight change or fatigue.

Cardiovascular

Denies.

Skin

Denies.

Respiratory

Denies.

Eyes

Wears glasses but otherwise denies. 

Gastrointestinal

Denies.

Ears

Denies. 

Genitourinary/Gynecological

Denies urinary issues.

Last PAP 2020, normal.

G0, P0

Not sexually active.

Takes oral contraception as above. 

Nose/Mouth/Throat

Denies.

Musculoskeletal

Denies.

Breast

Performs monthly SBE. Lump outer corner of left breast as described above. Denies nipple discharge or pain.

Neurological

Denies.

Heme/Lymph/Endo

Denies.

Psychiatric

Denies. Reports feeling anxious regarding presenting problem.

OBJECTIVE

Weight  5’8”      BMI 26.9

Temp 98.3

BP 128/74

Height 177lbs

Pulse 78, regular

Resp 14

General Appearance

Healthy-appearing adult female in no acute distress.

Skin

Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted.

HEENT

No palpable lymph nodes. Thyroid not palpable. Trachea midline.

Cardiovascular

S1, S2 with regular rate and rhythm. No murmurs, gallops or rubs.Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly.

Breast

Left breast lump 2cm in diameter, +skin retraction 3 O’clock position, 1cm from nipple. No nipple discharge noted. No tenderness.

Genitourinary

Speculum exam performed, cervix without lesions.

No visible discharge or blood noted in vaginal vault.

Uterus anteverted, mobile and nontender. Adnexa nontender and palpable bilaterally.

Digital rectal exam with no mass, good sphincter tone.

Musculoskeletal

Full ROM seen in all four extremities as the patient moved about the exam room. No joint pain or tenderness on palpation.

Neurological

Alert and oriented x 4. Speech clear. Good tone. Sensation intact.

Psychiatric

Alert and oriented with appropriate mood. Judgement intact. Answers questions appropriately.

Lab Tests/Imaging

Aerobic culture of the breast-negative

Bilateral diagnostic mammogram-BIRADS Category 5-High, suspicion of malignancy

Left breast biopsy under ultrasound guidance-Left Ductal Carcinoma in Situ.

Assessment

· Include at least three differential diagnoses

·
**Breast Abscess

·
**Fibroadenoma

·
**Fibrocystic breast disease

·
**Left breast lump, neoplastic

· Provide rationale for each differential diagnosis

· Final diagnosis—**Left breast ductal carcinoma in situ

· Pathophysiology of primary and rationale for choosing as final

Plan

· **discontinue oral combined hormonal contraceptive pill (CHC)

· **follow up in 3 months

· **refer to breast surgery

· **refer to genetic counselor

· **refer to oncology/radiation oncology

· Medications

· Non-pharmacological recommendations

· Diagnostic tests

· Patient education

· Culture considerations

· Health promotion

· Referrals

· Follow up