iHuman Rachel Hardy: Breast Disorder Complete Case Study
2023 VERSION/A+ GRADE COMPLETE CASE STUDY
CC: “I can feel two lumps in my breast.”
HPI:
... [Show More] 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
iHuman Rachel Hardy: Breast Disorder Complete Case Study
2023 VERSION/A+ GRADE COMPLETE CASE STUDY
Oxycodone 5mg 1 tab PRN Q4 pain
Amitriptyline 25mg 1 PO Q AM
ROS:
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 [Show Less]