Rachael Hardy – OBGYN
OBGYN Rachael Hardy
Rachael Hardy – OBGYN
CC – Two right breast lumps.
Diagnosis – breast mass/lump, neoplastic;
... [Show More] fibroadenoma; fibrocystic disease (breast cysts); breast
lipoma; fat necrosis; phyllodes tumor; breast abcess
Tests- Mammography, breast biopsy
• Epidemiology based data regarding risk factors key in diagnosis of breast lumps
•
• 10% heriditary
M – 25mcg levothyroixine, pancrelipase 15000u, oxycodone 5mg, amitriptyline 25mg
Problem Statement:
( Demographic description – chief complaint – Hx and PE key findings – risk factors )
Rachael is a 42 year old, G2P2 female presenting with complaint of two breast lumps in her Right breast.
Patient denies any blood, discharge, skin changes, or pain. Rachael has a history of Atypical ductal
hyperplasia in her Right breast 3 years ago. She also has had Right ovarian hemorrhagic cyst that
spontaneously resolved at an unknown time, she also has chronic idiopathic pancreatitis diagnosed in
her 20s, and hypothyroidism diagnosed at an unknown time. Physical exam shows 2 lumps in the right
breast 2.5cm at 2-o-clock position and 2.0cm at the 12-o-clock position both without skin fixation
inflammation or tenderness. Her risk factors include a family history of breast cancer (mother had
lumpectomy) as well as being mildly obese and her history of benign breast disease, previous alcohol use
and having kids later (aged 24, 32 for her births respectively).
CC: Two right breast lumps – found 6 months ago.
HPI: two breast lumps in her Right breast. Patient denies any blood, discharge, skin changes, or pain
Meds:
• 25mcg levothyroxine
• pancrelipase 15000u
• oxycodone 5mg as needed
• amitriptyline 25mg
PMH: Rachael has a history of Atypical ductal hyperplasia in her Right breast 3 years ago. She also has
had Right ovarian hemorrhagic cyst that spontaneously resolved at an unknown time, she also has
chronic idiopathic pancreatitis diagnosed in her 20s, and hypothyroidism diagnosed at an unknown time
FH: family history of breast cancer (mother had lumpectomy) [Show Less]