iHuman Rachel Hardy :Breast
Disorder Case Study
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I Human Rachel Hardy; Breast Disorder
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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
- 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:
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: [Show Less]