Northern Kentucky University

MSN 610: Diagnostic Reasoning and Advanced Physical Assessment

Comprehensive History & Physical Exam

DEMOGRAPHICS

Providers Name: Reneille Capanas Patient’s Initials: (Data Source) C.C

Date of Exam: July 2, 2019 Patient’s DOB/AGE: 40 years old

Chief Complaint:

“I’m just here for a wellness check-up. I just want to know my risks of having breast cancer since my mother

and my cousin was recently diagnosed with one.”

History of Present Illness:

• Seen and examined Mrs. C, a 40-year old, G2P2 presented in the clinic for a well-woman examination.

• She denies having any active medical condition but voices out concerns regarding breast cancer risk as her

mother and maternal cousin was just recently diagnosed with it.

• Patient reports having fibrocystic change said by her previous doctor. It was told the her cysts come and go

with her hormones from s menstrual period.

• She described her breast having a “lumpy-bumpiness”.Denies any pain or discomfort.

• First mammogram when she was 40 y.o with normal result

• Last mammogram check was 18 months ago and was normal. Patient also states that she does regular selfbreast examination and denies finding any lumps or having discharges.

Past Medical History:

Active Problems: Bilateral fibrocystic breast changes/cystic breast disease

Resolved Problems: none

Previous Hospitalizations/Surgical History:

OB/GYN: G2P2 normal deliveries

Tubal ligation: (35 years of age on second pregnancy)

Regular cleanings every 6 months

Allergies:

None to report

Current Medications:

Vitamin E daily for cystic breast disease

Ibuprofen, Aspirin or Acetaminophen as needed for headaches

Social History:

Ethinicity: Hispanic-American

Living Arrangements: married and living with husband for 13 years with 2 boys

Occupation/Environmental Safety: Middle school learning specialist with great support system.

 Denies problems with ADL. Walks to and from then train 5 days a

week; weekend gardening

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