NR 602 Week 1 iHuman Case 1 - Ms. Rachael Hardy

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Term	Year 2022
Institution	NR 602 Primary Care of the Childbearing and Childrearing Family
Contributor	Racheal Ofori

Description

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Week 1 NR 602 - iHuman Case

42Y/o 5’5 149lb

CC: Two right breast lumps

RH is a 42 year old female that presents with complaints of two right sided breast lumps. Patients mother was diagnosed with breast CA at age 48, currently still living. patient breast biopsy showed atypical ductal hyperplasia. she denies breast pain, discharge, bleeding, skin changes, palpable lymph nodes or fevers. she reports a recent 11lb weight loss over the past 3 months due to unknown cause.

Questions asked

How can I help you today?
Do you have any other symptoms that we should discuss
When did your problems with your breast start
Is there pain the site of the lump
Change in size
Is the lump movable
Any lumps in neck
Change in medications
No OTC medications
Vaccinations
Breast problem better or worse
Weight loss
Symptoms of Fatigue/
Chest pain or discomfort
Depression question
Use of Birth control
Mammogram
Nipple change
Pain anywhere
Changes in itchy scalp
Problems with headache
Muscle pain /joints
Change in ability
Nose bleeds
Breast self exam
Tender breasts
Early menopause
Hypothyroid
Pancreatic

Ms. Rachael Hardy is a 42-year-old woman who presents with two self-detected breast lumps. She had a prior breast biopsy three years ago that identified an atypical ductal hyperplasia. She denies breast discharge, bleeding, overlying skin changes, lymphadenopathy, fevers or past breast trauma. She reports an 11-pound weight loss due to diminished appetite over the last three months. Her mother was diagnosed with breast cancer at age 48 (I-Human, n.d.).................... Continue