NR 602 Week 1 iHuman Case 1 - Renata Chapman

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

Description

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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: warm, 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................... Continue