iHuman Rachel Hardy: Breast Disorder Case Study iHuman Rachel Hardy: Breast Disorder Case Study CC: “I can feel two lumps in my breast.” HPI: R.H. is a 42 year old female who presents with a chief complaint of two right-sided breast lumps that were self-detected. Patient's mother was diagnosed with breast CA at age 48, currently still living. Patient has a breast biopsy 3 years ago which showed atypical ductal hyperplasia. Patient denies any 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. Physical exam shows 2 palpable breast masses, one 2.5cm mass in the upper quadrant of the right breast, and another 2cm mass in the right breast. A right axillary lymph node that is hard and mobile is also palpable. Past Medical History - Chronic idiopathic pancreatitis - Hypothyroidism - Atypical ductal hyperplasia Past Surgical History Pancreas sx last year Social History - Tobacco use: 1-pack year history - Drug use: denies - Alcohol use: 2 glasses of wine per day starting at age 18; quit 6 years ago - Marital status: never married - Current/previous occupation: disabled due to chronic pancreatitis - Sexual orientation: female - Sexually active: not sexually active for past 12 years - Living situation: currently resides at home with 2 children Family History Mom- alive, breast CA at 48 Dad – alive, healthy Allergies No known drug allergies Active Medications Levothyroxine 25 mcg Q AM Pancrealipase 15000 units 2 tab before each meal Oxycodone 5mg 1 tab PRN Q4 pain Amitriptyline 25mg 1 PO Q AM ROS: General: Patient denies fevers, weight gain or loss, loss of appetite, night sweats, fatigue, or changes in sleeping. HEENT: Denies double or blurred vision, photophobia, discharge from eyes, or vision loss. Denies any abnormal nasal discharge, pain, or epistaxis. Denies hearing loss or tinnitus. CV: Denies any chest pains, palpitations or racing heart, bounding pulses, or edema. Respiratory: Denies any SOB, difficulty breathing, wheezes, or pain with inhalation/exhalation. GI: Denies any abdominal pain, nausea, vomiting, diarrhea, constipation, melena, or hematemesis. GU: Denies dysuria, frequency, hematuria, pain, or discharge. MS: Denies any new joint pains or swelling. Denies muscle pains, cramps, or weakness. Skin: Admits to two palpable right sided breast lumps. Denies any rashes or petechia, discharge, or abnormal pruritus. Denies any new skin lesions, or hair loss or increase. Neurologic: Denies any double vision, problems with walking or balance, weakness, or fainting. Psych: Denies memory loss, depression, agitation, suicidal thoughts, anxiety, mood swings, or hallucinations. Endocrine: Denies excessive thirst or urination, heat or cold intolerance, frequent hunger/urination/thirst, or changes in sex drive. Extremities: Denies pain or swelling, denies tingling or numbness to extremities. Allergic/Immunologic: Denies seasonal allergies, hay fever symptoms, itching, or frequent infections. Vital Signs: T: 98.4F PO P: 72 bpm BP: 116/68 RR: 16 bpm O2: 98% RA Height: 5’5 Weight: 149 lbs Physical Exam: • GENERAL: A pleasant Caucasian white female, alert and responsive, and appears in no acute distress. • INTEG: Skin appears warm, and normal in color and texture .No rash, pallor, or icterus noted. • LYMPH: Two palpable breast masses, one 2.5cm mass in the upper quadrant of the right breast, and another 2cm mass in the right breast. A right axillary lymph node that is hard and mobile is also palpable. • HEENT: Head Normocephalic, atraumatic. PERRLA, EOMI noted. Ears clear with normal tympanic membranes. Mucous membranes intact. Neck is supple without any masses or adenopathy. • CV: The external chest is normal in appearance without lifts, heaves, or thrills. S1, S2 heard, no S3. No rubs, murmurs, or gallops auscultated. No edema present. • RESP: Lungs clear to auscultation and percussion bilaterally in all lobes. No adventitious lung sounds auscultated. No evidence of chest trauma noted. • GI: Abdomen symmetric, soft and non-distended. Bowel sounds normoactive and positive in all 4 quadrants with no bruits noted. • NEURO: A&O x4. Motor strength is normal, 5/5 bilaterally to upper and lower extremities. Sensation is intact bilaterally. Reflexes +2 bilaterally. • PSYCH: Appropriate mood and affect. No visual or auditory hallucinations. No memory loss, depression, or suicidal thoughts. Labs/Diagnostics: Mamogram: Abnormal, highly suspicious for breast cancer Breast biopsy: - Invasive duct carcinoma: estrogen-receptor positive; progesterone-receptor positive; HER2/neu negative - Right-axillary lymph node: metastatic breast adenocarcinoma Diagnosis: 1. Breast mass/lump, neoplastic Differential Diagnosis Breast abscess Fibroadenoma Fibrocytic disease (breast cysts) Breast lipoma Fat necrosis Phyllodes tumor Plan Non-pharmacologic: Referral to oncology specialist for possible surgical removal of breast lumps, radiation, and medical management. Pharmacologic: None at this time Follow-up: In 2 weeks in primary care office after scheduled visit with oncologist specialist to reassess recommendations.