Female Genitourinary, & Musculoskeletal

Case 1

Chief

Complaint

(CC)

“I have a tumor on my left breast”

History of

Present Illness

(HPI)

A 55-year-old African American social worker presents to your clinic with a finding of a lump in her left breast while in the shower this past week.

Drug Hx

I took birth control pills for 10 years, starting when I was 20 l am not on hormone replacement

Family Hx

My grandmother had breast cancer when she was 76 years old

Subjective

Denies any fever or chills. No changes in vision or hearing, no difficulty chewing or swallowing. Supple neck, states that she does self-breast-exams on occasion. Menopause at 52

No skin changes or nipple discharge from the left breast

Objective Data

 VS

temperature 98.6°F; respiratory rate (RR) 16; heart rate (HR) 80, regular; blood pressure (BP) 130/84; height: 5′8″; weight 160 lbs; body mass index (BMI) 24

temperature: 98.2°F, respiratory rate 16, heart rate 90, blood pressure 120/60 
O2 saturation 98% 

 General

well developed, nourished, healthy-appearing female

well-developed healthy 35-year-old male; no gross deformities

 HEENT

Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous. 

Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries. 

Lungs

clear to auscultation 

CTA AP&L

Card

regular rate and rhythm (RRR)

S1S2 without rub or gallop

Breast

Examined in sitting and supine positions. In sitting position, no evidence of skin changes, right breast is slightly larger than the left, symmetrical movement with the arms above the head and at the side and with flexion of the pectoral muscles; 5-mm nonmobile, non-tender, firm mass felt at 10 o’clock position, 5 cm from the areola. Right breast without dominant masses or tenderness. Nipples without inversion or evidence of nipple discharge. Breast mass is palpated in the supine position in the same manner as in the sitting position

• INSPECTION: no dimpling or abnormalities noted upon inspection

• PALPATION: Left breast – no abnormalities noted. Right breast – denies tenderness, pain, no abnormalities noted.

Lymph

negative axillary, infraclavicular, and supraclavicular lymphadenopathy

no bruising, fever, or swelling noted, no acute bleeding or trauma to skin.

Abd

normoactive bowel sounds x 4; 

benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.

GU

Bladder is non-distended.

Bladder is non-distended.

Integument

good skin turgor noted, moist mucous membranes

intact without lesions masses or rashes.

MS

Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation.

No obvious deformities, masses, or discoloration. Palpable pain noted at the right lower lumbar region. No palpable spasms. ROM limited to forward bending 10 inches from floor; able to bend side to side but had difficulty twisting and going into extension. 

Neuro

No obvious deformities, CN grossly intact II-XII

DTRs 2+ lower sensory neurology intact to light touch and patient able to toe and heel walk. Gait was stable and no limping noted.

Criteria

Ratings

Points

dentification of

Main Issues, Problems, and Concepts

Distinguished – 5 points

Identify and demonstrate a

sophisticated understanding of the accomplished understanding of issues, problems, and concepts.

Excellent – 4 points

Identifies and demonstrate an

most of issues, problems, and concepts.

Fair – 2 points

Identifies and demonstrate an

issues, problems, and concepts.

Poor – 1 point

Identifies and demonstrate an

acceptable understanding of most of unacceptable understanding of most 5 points

of issues, problems, and concepts.

Use of Citations,

Writing

Mechanics and

APA Formatting

Guidelines

Distinguished – 3 points

Effectively uses the literature and other resources to inform their

work. Exceptional use of citations and extended referencing. High level of APA precision and free of grammar and spelling errors.

Excellent – 2 points

other resources to inform their work. Moderate use of citations and extended referencing.

Moderate level of APA precision

and free of grammar and spelling precision and attention to detail. errors.

Fair – 1 point

Effectively uses the literature and Ineffectively uses the literature and

other resources to inform their work. other resources to inform their work.

Moderate use of citations and

extended referencing. APA style and and extended referencing. APA style writing mechanics need more

Poor – 0 points

Ineffectively uses the literature and

An unacceptable use of citations

and writing mechanics need serious attention.

3 points

Distinguished – 2 points

Response to

Student constructively responded to two other posts and either

Posts of Peers

extended, expanded or provided a rebuttal to each.

Fair – 1 point

Student constructively responded to Student provided no response to a one other post and either extended, expanded or provided a rebuttal.

Poor – 0 points

peer’s post.

2 points

Total Points

10