Case 1 | |||
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 l 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 | ||
Objective Data | |||
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 | temperature: 98.2°F, respiratory rate 16, heart rate 90, blood pressure 120/60 | |
General | well developed, nourished, healthy-appearing female | well-developed healthy 35-year-old male; no gross deformities | |
HEENT | Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous. | Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries. | |
Lungs | clear to auscultation | CTA AP&L | |
Card | regular rate and rhythm (RRR) | S1S2 without rub or gallop | |
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 | • INSPECTION: no dimpling or abnormalities noted upon inspection • PALPATION: Left breast – no abnormalities noted. Right breast – denies tenderness, pain, no abnormalities noted. | |
Lymph | negative axillary, infraclavicular, and supraclavicular lymphadenopathy | no bruising, fever, or swelling noted, no acute bleeding or trauma to skin. | |
Abd | normoactive bowel sounds x 4; | benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin. | |
GU | Bladder is non-distended. | Bladder is non-distended. | |
Integument | good skin turgor noted, moist mucous membranes | intact without lesions masses or rashes. | |
MS | Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation. | No obvious deformities, masses, or discoloration. Palpable pain noted at the right lower lumbar region. No palpable spasms. ROM limited to forward bending 10 inches from floor; able to bend side to side but had difficulty twisting and going into extension. | |
Neuro | No obvious deformities, CN grossly intact II-XII | DTRs 2+ lower sensory neurology intact to light touch and patient able to toe and heel walk. Gait was stable and no limping noted. |
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?
Submission Instructions:
· Your instructor will assign you your case number and you will post on the case number you have been assigned.
· You will reply to
the other two case studies (One of each).
· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
· Discussion Rubric
Criteria | Ratings | Points | |||
dentification of Main Issues, Problems, and Concepts | Distinguished – 5 points Identify and demonstrate a sophisticated understanding of the accomplished understanding of issues, problems, and concepts. | Excellent – 4 points Identifies and demonstrate an most of issues, problems, and concepts. | Fair – 2 points Identifies and demonstrate an issues, problems, and concepts. | Poor – 1 point Identifies and demonstrate an acceptable understanding of most of unacceptable understanding of most 5 points of issues, problems, and concepts. | |
Use of Citations, Writing Mechanics and APA Formatting Guidelines | Distinguished – 3 points Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. High level of APA precision and free of grammar and spelling errors. | Excellent – 2 points other resources to inform their work. Moderate use of citations and extended referencing. Moderate level of APA precision and free of grammar and spelling precision and attention to detail. errors. | Fair – 1 point Effectively uses the literature and Ineffectively uses the literature and other resources to inform their work. other resources to inform their work. Moderate use of citations and extended referencing. APA style and and extended referencing. APA style writing mechanics need more | Poor – 0 points Ineffectively uses the literature and An unacceptable use of citations and writing mechanics need serious attention. | 3 points |
Distinguished – 2 points Response to Student constructively responded to two other posts and either Posts of Peers extended, expanded or provided a rebuttal to each. | Fair – 1 point Student constructively responded to Student provided no response to a one other post and either extended, expanded or provided a rebuttal. | Poor – 0 points peer’s post. | 2 points | ||
Total Points | 10 |
