A lump in the breast can be considered cancerous or non-cancerous. The Ihuman case study below is based on Rachel Hardy's evaluation of her health. Below find the problem statement, history, tests and conclusions.
Chief Complaint: Rachel Hardy
HPI: Ms. Rachel Hardy is a 42 year old female that presents with a 6 month history of two self-detected lumps in right breast. Patient reports maternal history of breast cancer (mother age 48) and a personal history of breast biopsy 3 years ago revealing atypical ductal hyperplasia. She denies breast discharge, bleeding, skin changes, lymphadenopathy, breast trauma, or fevers. Endorses11 pound weight loss of 3 months related to diminished appetite. Physical exam reveals a palpable 2.5 cm mass in the upper-inner quadrant of the right breast at the 2 o'clock position and a 2 cm, right breast mass at the 12 o'clock position. A hard, mobile, right axillary lymph node is palpable.
PMhx : Hypothyroidism Idiopathic, chronic Pancreatitis Atypical ductal hyperplasia
Last mammogram: 3 years
No history of pap smear or pelvic exam Tubal ligation
Puestow procedure Breast biopsy: 3 years ago
Levothyroxine 25 mcg daily
Pancrelipase 15000units, take 2 tablets before each meal Oxycodone PRN pain
Amitriptyline 25 mg daily Pap smear not up to date
Mammogram 3 years ago: atypical ductal hyperplasia Maternal: Breast cancer age 48 (Alive)
Paternal: "Healthy" (Alive)2 living children
Pt is on disability for pancreatitis Tobacco use age 18-20,none at this time
No alcohol use, quit 6 years ago
Denies illicit drug use Sedentary lifestyle (disabled) 2 living children
Never married
Physical Examination:
Skin: Skin is warm, dry and intact without rashes or lesions. Appropriate color for ethnicity. Nails without ridging, pitting. Breast normal and symmetrical in contour. No skin dimpling, retractions, or scarring. No areolar/nipple erosion or visible drainage. Breast non-tender to exam bilaterally. No nipple blood/drainage evoked by exam. Right 2.5cm mass palpable in the upper-inner quadrant in the 2'oclock position; no skin fixation or inflammation. Right: a second 2.0cm lesion is palpable at the 12 o'clock position.no skin inflammation or fixation.
Left breast: no suspicious lesions or abnormal findings.
Head: The head is normo-cephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring.
Hair: Hair is of normal texture and evenly distributed.
Neck: The neck is supple without adenopathy.
Trachea: Trachea is midline.
Thyroid: Thyroid gland is normal without masses.
Eyes: Pupils equal, round and reactive to light.
Chest: The external chest is normal in appearance without lifts, heaves, or thrills.
PMI: PMI is not visible and is palpated in the 5th intercostal space at the midclavicular line. Heart rate and rhythm are normal. No murmurs, gallops, or rubs are auscultated. S1 and S2 are heard and are of normal intensity.
The anterior lung fields are resonant. Left anterior chest and right lower chest dull to percussion. The rest of the lung fields are resonant and re not hyper-resonant. Lung sounds clear, equal, and present in all lung fields. The chest is symmetrical and the AP diameter is normal. No distention, scars, masses, or rashes.
Abdomen mildly obese, non distended. A well-healed C-section scar is present. Non-tender to palpation throughout. No palpable masses or herniation. No tympany.
normal in appearance without lesions, swelling, masses or tenderness.
Normal bulk and tone. No rigidity. No asymmetry or deformity of the back. No tenderness or spasms of the paraspinal muscles. No localized tenderness.
No swelling or deformities noted. No neurological deficits noted.
Appropriate mood and affect. Good judgement and insight. No visual or auditory hallucinations. No suicidal or homicidal ideation.
None noted.
One-centimeter right axillary lymph node; firm, but mobile. Remainder of lymph-node assessment negative.
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