22 Jun Case study Female Genitourinary, & Musculoskeletal

1. What other subjective data would you obtain?

2. What other objective findings would you look for?

3. What diagnostic exams do you want to order?

4. Name 3 differential diagnoses based on this patient presenting symptoms?

5. Give rationales for your each differential diagnosis.

6. What teachings will you provide?

case study #1

Female Genitourinary, & Musculoskeletal

Chief Complaint (CC) “I have a tumor on my left breast”

History of Present Illness (HPI) A 55-year-old African American social worker presents to your clinic with a finding of a lump in her left breast while in the shower this past week.

Drug Hx I took birth control pills for 10 years, starting when I was 20 I am not on hormone replacement

Family Hx My grandmother had breast cancer when she was 76 years old

Subjective Denies any fever or chills. No changes in vision or hearing, no difficulty chewing or swallowing. Supple neck, states that she does self-breast-exams on occasion. Menopause at 52 No skin changes or nipple discharge from the left breast

 VS temperature 98.6°F; respiratory rate (RR) 16; heart rate (HR) 80, regular; blood pressure (BP) 130/84; height: 5′8″; weight 160 lbs; body mass index (BMI) 24

General well developed, nourished, healthy-appearing female

HEENT Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.

Lungs clear to auscultation

Card regular rate and rhythm (RRR)

Breast Examined in sitting and supine positions. In sitting position, no evidence of skin changes, right breast is slightly larger than the left, symmetrical movement with the arms above the head and at the side and with flexion of the pectoral muscles; 5-mm nonmobile, non-tender, firm mass felt at 10 o’clock position, 5 cm from the areola. Right breast without dominant masses or tenderness. Nipples without inversion or evidence of nipple discharge. Breast mass is palpated in the supine position in the same manner as in the sitting position

Lymph negative axillary, infraclavicular, and supraclavicular lymphadenopathy

Abd normoactive bowel sounds x 4;

GU Bladder is non-distended.

Integument good skin turgor noted, moist mucous membranes

MS Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation.

Neuro No obvious deformities, CN grossly intact II-XII

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