NR 602 Week 1 iHuman Case 1 – Physical Exam (Renata Chapman)

Document Content and Description Below

NR 602 Week 1 iHuman Case 1 – Physical Exam (Renata Chapman) Renata Chapman 42-year-old female Height 5’5 (165 cm) Weight 149.0 lb (67.7 kg) Chief complaint: Two right-breast lumps Skin: wa... rm, dry HPI (History of present illness): Name: Renata Chapman Age: 42 years Sex: F Height: 5' 5" (165.0 cm) Weight: 149 lb (68.0 kg) (BMI 24.8) Temperature: 98.4 F (oral) Pulse: 72 bpm - regular Blood pressure: 116/68 mmHg - supine/sitting Blood pressure: 102/62 mmHg - upon standing Respiratory rate: 16 bpm SpO2: 98% on room air PMH (Pervious medical history): Allergies: None Oth er acti ve p roblem s : Right-ovarian hemorrhagic cyst (spontaneously resolved): year unknown Chronic idiopathic pancreatitis: diagnosed in her 20s Hypothyroidism: age at time of diagnosis not recalled Me dical , surgical , obst e t r i c , hospit a l i zatio ns: OB/GYN: Menarche age 14; G2P2; first pregnancy at age 25 vaginal; second at age 32 C-section 7 years ago, follow by a bilateral tubal ligation (BTL) Preve ntiv e He alth : Full childhood vaccinations Exercise: None; sedentary Diet: Predominantly fast foods aunt junk food per patient's account Immuniza t io ns: Immunizations: none in the last 7 years Completed childhood-vaccination schedule Medications: Levothyroxine 25 mcg one tablet daily Pancrelipase 15000 units two tablets before each meal and snack Oxycodone 5 mg one tablet every four hours as needed Amitriptyline 25 mg one tablet daily Family History: Mother: alive; breast cancer diagnosed at age 48 (lumpectomy, no known recurrence) Father: alive and healthy Siblings: none Social History: Occupation: Disabled due to chronic pancreatitis Marital status: Never married; lives with her two children Sexual history: Not sexually active for the last 5 years; negative HIV test sometime within the last 7 years Alcohol use: Two glasses of wine a day starting at 18 years of age; none for six years Tobacco use: Less than one pack a day from 18-20 years of age; none since Illicit drugs: None/never ROS (Review of System): General/Constitutional: Negative Sk in/ Bre ast: Negative---did not feel anything prior to mammographic finding HEEN T & N e ck : Negative Cardiovascul ar: Negative Re spiratory: Negative Abdome n/ Gastroi nte s t inal : Negative Ge nitouri nary: Negative Muscul osk e l e tal : Negative N e urol ogical : Negative Al l e rgic/ Immunol ogic: Negative L ymphatic/ Endocri ne : Negative He matol ogic: Negative Psychol ogical : Negative Vital signs: Temp: 98.6F Pulse: 70, rhythm: Regular BP: Left 116/70 Respiration: 16, effort: unlabored Physical exam: 148.0 pounds deferred on this follow-up visit Sk in/ Bre ast: HEEN T & N e ck : deferred on this follow-up visit deferred on this follow-up visit deferred on this follow-up visit deferred on this follow-up visit deferred on this follow-up visit deferred on this follow-up visit deferred on this follow-up visit deferred on this follow-up visit deferred on this follow-up visit deferred on this follow-up visit Test Results: Stereotactic Biopsy Results: Atypical ductal hyperplasia in right breast. Management Plan: Cardiovascul ar: Re spiratory: Abdome n/ Gastroi nte s t inal : Ge nitouri nary: Muscul osk el e tal : N e urol ogical : Al l e rgic/ Immunol ogic: L ymphatic/ Endocri ne : He matol ogic: Discussed incidence of Atypical ductal hyperplasia progressing to Ductal Carcinoma In situ. Recommended close follow-up. Suggested consider genetic testing of mother to determine risk for malignancy. Suggest follow-up appointment in 6 months with repeat mammogram also in 6 months. • Tubal ligation • Pancreatitis surgery • Breast biopsy This study source was downloaded by 100000829957125 from CourseHero.com on 09-06-2021 07:21:48 GMT -05:00 This study source was downloaded by 100000829957125 from CourseHero.com on 09-06-2021 07:21:48 GMT -05:00 [Show More]

Last updated: 1 year ago

Preview 1 out of 7 pages