Patient Initials: S.M
Pt. Encounter Number: 2
Advanced Directives: No
Chief Complaint: “I have a lump on my right breast.”
HPI: S.M is a 61-year-old, Hispanic, female who presents to the office alarmed by a painful lump in her right breast that she discovered while showering. S.M reports the pain started 2 days ago while in the shower. The pain is felt when touching the right breast, and it felt on light touch. Current pain level is now 5/10. She does not report any skin changes. Patient denies any history of herbal medicine use and is currently on no medication. Pain gets worse with movement and with lifting weight. Pain is relieved with rest and medication. S.M gets some short relief with pain reliever ibuprofen 200mg that she takes twice a day for the past two days.
Past Medical History
Medication Intolerances: No known drug intolerance
Chronic Illnesses/Major traumas: The patient denies any history of major trauma.
Screening Hx/Immunizations Hx: last mammogram, which was normal, was 2 years ago.
OBGYN: Menarche at 10; LMP 2 weeks ago; last PAP 2019/Normal; GTPAL: 11001 score; no previous history of STDs. S.M is sexually active, have had 2 sexual partners in the past. S.M used condoms with previous partners. No previous gyn diagnoses or procedures done in the past.
Hospitalizations/Surgeries: Hospitalized once for delivery
Family History: There is no history of malignancy in first-degree relatives. She has one sister, age 58, who is in good health. Mother died at age 70; father died at age 64, from unknown causes.
Social History: S.M is married with one child. No use of alcohol; drinks wine socially; drinks one cup of coffee sometime to start her day at work. Never uses drugs.
Review of System
Constitutional: No significant gain/loss weight, no chills, no malaise or fatigue; no night sweats, no exercise intolerance. She does not report any skin changes. She has not experienced fever, weight loss, headache, nausea, vomiting, dizziness, or bone pain.
Skin: Denies rashes, pigmentation changes, lesions, or hair or nail changes.
Eyes: denies vision changes, diplopia, blurred vision, reports wearing eyeglasses.
Ears: Denies loss of hearing, ear pain, drainage, sensation of ears feeling full, ringing in the ear, or ear trauma.
Nose/Mouth/Throat: Denies sore throat, hoarseness, difficulty swallowing, postnasal
drip. No report of mouth or lips sore, bleeding gums, ulcerations or lesions of tongue or
mucosa; no dentures or dental appliances, or missing teeth reported.
Breast: Refers to right breast pain, or discomfort to right breast. Reports some brownish nipple discharges when squeezing the nipple and denies any breast trauma.
Heme/Lymph/Endo: Denies history of anemia, no bruising, no abnormal bleeding, and no swollen glands.
Cardiovascular: Denies chest pain, palpitations, orthopnea, edema, claudication, murmurs, or history of cardiac disease.
Respiratory: S.M reports no cough, sputum, wheezing, no recurrent URIs, hemoptysis,
bronchitis, pneumonia, or history of TB.
Gastrointestinal: Patient denies abdominal pain, nauseas, or vomiting. Denies bloating,
flatulence, diarrhea, constipation, changes in stools; black tarry stools, or bright rectal
bleeding after defecation. S.M reports normal appetite.
Genitourinary/Gynecological: denies dysuria, frequency, urgency, and urge to urine after she had emptied her bladder. Denies nocturia, or hematuria; denies genital discharge, or sensation of bladder fullness; no abnormal bleeding, and no history of STD.
Musculoskeletal: No muscular aches or weakness, no arthralgia, denies history of falls, no loss of balance.
Neurological: Denies changes in LOC, Denies history of tremors, seizure, weakness, numbness, dizziness, headaches, memory lapses or loss. Denies sleep disturbances.
Psychiatric: Denies hallucination, depression, or any thoughts to harm self or others. Also denies psychosocial, or emotional disorder at this point in time.
Vital Signs: BP: 130/78, P: 74, R18; T: 97.3; O2 Sat: 99 %. Wt.: 170 lb. Ht. 5’5″, BMI: 28.29.
General Appearance: S.M is awake, alert, and oriented to time, space, and person. Speaks clearly and follows simple commands. Well nourished, developed and dressed/groomed, pleasant demeanor. Appears to be without discomfort, does not look distressed.
Skin: Normal general appearance. Warm, moist, good skin turgor. No cyanosis, rashes, or lesions noted. No wound, no change in a mole, no unusual growth, no jaundice, no bruising, no bleeding.
HEENT: Head: Is normocephalic, atraumatic, and without lesions. No tenderness elicited on palpation with both temporal pulses being regular.
Eyes: Are normal with PERRLA; with pinkish conjunctiva and whitish sclera implying no jaundice or anemia.
Ears: There is mild cerumen on external auditory meatus; tympanic membranes are also intact and pearly gray in color, with presence of light reflex.
Nose and sinuses: The patient has moist nasal mucosa with no drainage and mid sagittal septum. External nares are patent, and frontal and maxillary sinuses non-tender on palpation.
Mouth: The patient has a good oral hygiene. The lips, gums, tongue, and hard palate are normal, with all teeth intact with no discolorations. The oropharynx is moist and pinkish with no apparent enlargement of the tonsils (Hollier, 2016).
Neck: The assessment depicts no apparent tracheal deviation, without thyroid and lymph nodes not palpable. All movements are normal.
Cardiovascular: The anterior chest wall is symmetrical with AP diameter less than lateral diameter. Both S1 and S2 heard on auscultation at all valve areas with no added sounds. The apex beat at fifth intercostal space, mid clavicular line, with neither heaves nor thrills. Capillary refill is 2 second, with pulses 3+ throughout and no edema.
Respiratory: Unlabored respiration, lungs are clear bilaterally to auscultation. Breath sounds are normal on auscultation.
Gastrointestinal: Abdomen is soft, no rebound tenderness, masses, scars, herniation, or guarding. Bowels sound present to all 4 quadrants, no organomegaly, or bruits. No sign of active GI bleed.
Breast: There are no visible abnormalities on sitting or supine exam. Left breast and axilla are normal. Right breast with about 2 cm tender hard, color changed, immobile lesion with irregular borders, in superior lateral quadrant approximately 6 cm from areola. There is no palpable axillary, or supra-clavicular lymph nodes.
Genitourinary: The kidney was bimanually not palpable and non-tender, no sign of costo-vertebral angle tenderness. The bladder was not distended and devoid of urine prior to examination (Hollier, 2016).
Musculoskeletal: Full range of motion in all extremities. No abnormalities in gait or movement.
Neurological: Alert, oriented to time, place and person, Neurologic grossly intact. Memory to recent and remote events preserved. Sensation intact and preserved strength to bilateral upper and lower extremities.
Psychiatric: Patient has good judgment; mood and affect are normal. No anxiety, or depression, no irritability, and no mood swing.
Lab Tests: U/A, and C/S, no growth, WBC 5.6 and H/H 9.5/31(July 2020).
Special Tests: Last mammogram 2019/ negative; Pap smear 2018/normal
C50.9- Breast cancer– Patient presents to the clinic and alarmed by a painful lump in her right breast that she discovered while showering. The reported symptoms and signs noted on physical examination suggest findings of breast carcinoma which can be justified with a mammogram and other studies (Burstein, Lacchetti, & Griggs, 2016).
N64.89- Galactocele– Patient presents to her clinic alarmed by a painful lump in her right breast that she discovered while showering (Burstein, Lacchetti, & Griggs, 2016).
N60.0- Breast cyst– The patient presents to her internist alarmed by a painful lump in her right breast. Tender breast lumps are a common presentation and could point out to a wide variety of diseases. As such, it is necessary to conduct a detailed history to come up with a detailed diagnosis. On the case of S.M, histology would be of great significance to come up with a definitive diagnosis. (Burstein, Lacchetti, & Griggs, 2016).
N64.4- Mastodynia- S.M shows sign and symptom of breast tenderness of unknown cause which requires further investigation.
PLAN and education
Test: Bilateral breast mammography and Right breast U-S
Ultrasound-guided ultrasonography for histology to confirm breast cancer
Medications: Ibuprofen 400mg PO as needed TID for pain for 10 days.
Non-pharmacological treatments: applied warm compress as tolerated daily; and practice aerobic exercise for at least 1 hour a day and three days in a week for overweight to manage weight. (Hollier, A. (2016)
Education: The patient is to be educated on taking the prescribed medication and the associated side effects (Burstein, Lacchetti, & Griggs, 2016).
Beware of Ibuprofen side effects: heartburn, stomach pain, nausea, gas, and constipation (Healthline.com)
Referrals: None for now, pending Mammogram and U-S results.
Follow: Patient to come back to the clinic in 1week for histological results.
Burstein, H. J., Lacchetti, C., & Griggs, J. J. (2016). Adjuvant Endocrine Therapy for Women With Hormone Receptor–Positive Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update on Ovarian Suppression Summary. Journal of oncology practice, 12 (4), 390-393.
Hollier, A. (2016). Clinical guidelines in primary care. Scott, LA: Advanced Practice breastfeeding Associates
Mastitis (n.d). Miami Cancer Institute. Retrieved from
Understanding How Ibuprofen works (n.d). Healthline. Retrieved from
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