P.I: T.R
Gender : Female
Age : 30
Subjective:
CC: “I noticed this tender area on my breast.”
HPI: Mrs. R is a Caucasian female aged thirty years old. Mrs. R has no significant medical history and presents to the office today, complaining of a tender region on her bilateral nipple and axilla for more than two weeks. Mrs. Are also states that she has itchiness and redness. Mrs. R denies swelling of the breast, fever, or nipple discharge. Mrs. R denies having experienced recent trauma, lumps, procedures, or swelling around the breast area. Mrs. R has level pain of 5/10. Mrs. R conducts a self-breast exam every month for the past twelve years.
Medication: Acetaminophen to relieve pain
Selective serotonin reuptake inhibitor (SSRI) for depression
PMH: Urinary tract infection, Constipation, Cholecystitis cholecystectomy
Allergies: No known allergies
Family History: Mrs. R denies any family history of uterine, breast, or ovarian cancer. Sister aged 25, normal, and healthy. Brother, aged 18, normal, and healthy. Mother aged 50 still alive with HTN. Father dead, aged 40, Diabetes Mellitus. Paternal Grandmother still alive aged 70, arthritis. Paternal Grandfather is alive, aged 75, prostate cancer. Maternal-Grandfather: dead aged, 78, COPD. Maternal grandmother dead, aged 85, renal failure.
Delegate your assignment to our experts and they will do the rest.
Social History: Mrs. R is a single mother with a daughter aged six years. Mrs. R got pregnant while in college. Mrs. R is employed as an accountant in a local firm. Mrs. R admits to not being very social and keeps a small circle of friends. Mrs. R denies smoking; however, she admits to occasionally taking alcohol, especially when depressed.
Review of Systems
General: Mrs. R denies fever, chills or fatigue
Skin: Rash and itching present around bilateral nipple and axilla. Denies changes in hair and nails.
HEENT: Mrs. R denies vertigo or headache. Mrs. R denies visual changes of any kind. Mrs. R denies ear discharge, hearing loss of ear pain. Mrs. R denies nasal congestion. Mrs. R denies bleeding of gums.
Neck: Neck appears normal and denies pain or discomfort.
Respiratory: Mrs. R denies sneezing, cough, wheezing, or SOB.
Cardiovascular: Mrs. R denies dyspnea, palpitations or chest pains.
Gastrointestinal: No appetite loss. Normal bowel movements. Constipation.
Breasts: Positive for tenderness and redness around bilateral nipple and axilla. Complains of discomfort and pain. Denies nipple discharge. Denies any history of mammograms or ultrasound on the breast.
Objective
Weight: 58.5kg, Temp: 36 ο C, BP: 118/84, Height: 62”, Resp: 16 Pulse : 70
General: The patient is comfortable and well-groomed. The patient is calm though it shows signs of distress. Breast pain is noted during the conversation to bilateral axilla as the patient continues to itch. Gait is normal, and the posture is relaxed.
Breast appearance: No dimpling, No discharge, No discoloration of the skin, and breast pigmentation matches her race. Breasts are symmetrical. Breast is tender and slight redness observed around the areola.
Inspection: Mrs. R maintains an upright posture with arms to the side. Breasts are round, symmetrical, and smooth in texture. No sores discharge or sores. Tenderness around the bilateral areola and nipple. Nipple or areolae have no scales. Nipples everted and points in the same direction—slight rash on the axilla, beginning from the tail of Spence apex and extending to the axilla.
Palpation: Mrs. R is lying in a supine position with arms overhead during all breast examinations.
Breasts: Inspected using vertical strip from the nipple. Bilateral tissue is soft devoid of fibrous texture. Palpable lumps absent. Breast is tender.
Axilla: Inspected lateral, subscapular and pectoral nodes. Palpable lumps absent. Tenderness present.
Anticipatory guidance: The significance of conducting monthly breast exams, in the same way, every time. Recommended use of antidepressants, especially SSRI, which have been associated with increased breast pain. Follow up in two weeks to examine the effectiveness and likely need for further screening of breast.
