RN 602 RENATA CHAPMAN IHUMAN CASE
STUDY NEW SOLUTION 2023 CC:TWO RIGHT
BREAST LUMPS, SKIN WARM AND DRY
Renata Chapman
42-year-old female
Height
... [Show More] 5’5 (165 cm)
Weight 149.0 lb (67.7 kg)
Chief complaint: Two right-breast lumps
Skin: warm, dry
HPI (History of present illness):
Name: Renata Chapman
Age: 42 years
Sex: F
Height: 5' 5" (165.0 cm)
Weight: 149 lb (68.0 kg) (BMI 24.8)
Temperature: 98.4 F (oral)
Pulse: 72 bpm - regular
Blood pressure: 116/68 mmHg - supine/sitting
Blood pressure: 102/62 mmHg - upon standing
Respiratory rate: 16 bpm
SpO2: 98% on room air
PMH (Pervious medical history):
Allergies: None
Oth er acti ve p roblem s :
Right-ovarian hemorrhagic cyst (spontaneously resolved): year unknown
Chronic idiopathic pancreatitis: diagnosed in her 20s
Hypothyroidism: age at time of diagnosis not recalled
Me dical , surgical , obst e t r i c , hospit a l i zatio ns:
OB/GYN: Menarche age 14; G2P2; first pregnancy at age 25 vaginal; second at age 32 C-section 7 years
ago, follow by a bilateral tubal ligation (BTL)
Preve ntiv e He alth :
Full childhood vaccinations
Exercise: None; sedentary
Diet: Predominantly fast foods aunt junk food per patient's account
Immuniza t io ns:
Immunizations: none in the last 7 years
Completed childhood-vaccination schedule
Medications:
Levothyroxine 25 mcg one tablet daily
Pancrelipase 15000 units two tablets before each meal and snack
Oxycodone 5 mg one tablet every four hours as needed
Amitriptyline 25 mg one tablet daily
Family History:
Mother: alive; breast cancer diagnosed at age 48 (lumpectomy, no known recurrence)
Father: alive and healthy
Siblings: none
Social History:
Occupation: Disabled due to chronic pancreatitis
Marital status: Never married; lives with her two children
Sexual history: Not sexually active for the last 5 years; negative HIV test sometime within the last 7 years
Alcohol use: Two glasses of wine a day starting at 18 years of age; none for six years
Tobacco use: Less than one pack a day from 18-20 years of age; none since
Illicit drugs: None/never
ROS (Review of System):
General/Constitutional: Negative
Sk in/ Bre ast: Negative---did not feel anything prior to mammographic finding
HEEN T & N e ck : Negative Cardiovascul ar:
Negative
Re spiratory: Negative
Abdome n/ Gastroi nte s t inal : Negative
Ge nitouri nary: Negative
Muscul osk e l e tal : Negative
N e urol ogical : Negative
Al l e rgic/ Immunol ogic: Negative
L ymphatic/ Endocri ne : Negative
He matol ogic: Negative
Psychol ogical : Negative
Vital signs:
Temp: 98.6F
Pulse: 70, rhythm: Regular
BP: Left 116/70
Respiration: 16, effort: unlabored [Show Less]