Take on the role of a clinician who is building a health history for one of the following case

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 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 52No 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

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’s presenting symptoms.
5. Give rationales for each differential diagnosis.
6. What teachings will you provide?