Rachael Hardy – OBGYN, 2022/2023

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Rachael Hardy – OBGYN CC – Two right breast lumps. Diagnosis – breast mass/lump, neoplastic; fibroadenoma; fibrocystic disease (breast cysts); breast lipoma; fat necrosis; phyllodes tumor; br... east abcess Tests- Mammography, breast biopsy  Epidemiology based data regarding risk factors key in diagnosis of breast lumps   10% heriditary M – 25mcg levothyroixine, pancrelipase 15000u, oxycodone 5mg, amitriptyline 25mg Problem Statement: ( Demographic description – chief complaint – Hx and PE key findings – risk factors ) Rachael is a 42 year old, G2P2 female presenting with complaint of two breast lumps in her Right breast. Patient denies any blood, discharge, skin changes, or pain. Rachael has a history of Atypical ductal hyperplasia in her Right breast 3 years ago. She also has had Right ovarian hemorrhagic cyst that spontaneously resolved at an unknown time, she also has chronic idiopathic pancreatitis diagnosed in her 20s, and hypothyroidism diagnosed at an unknown time. Physical exam shows 2 lumps in the right breast 2.5cm at 2-o-clock position and 2.0cm at the 12-o-clock position both without skin fixation inflammation or tenderness. Her risk factors include a family history of breast cancer (mother had lumpectomy) as well as being mildly obese and her history of benign breast disease, previous alcohol use and having kids later (aged 24, 32 for her births respectively). CC: Two right breast lumps – found 6 months ago. HPI: two breast lumps in her Right breast. Patient denies any blood, discharge, skin changes, or pain Meds: This study source was downloaded by 100000856694432 from CourseHero.com on 11-11-2022 15:08:10 GMT -06:00 https://www.coursehero.com/file/62247317/OBGYN-Rachael-Hardydocx/  25mcg levothyroxine  pancrelipase 15000u  oxycodone 5mg as needed  amitriptyline 25mg PMH: Rachael has a history of Atypical ductal hyperplasia in her Right breast 3 years ago. She also has had Right ovarian hemorrhagic cyst that spontaneously resolved at an unknown time, she also has chronic idiopathic pancreatitis diagnosed in her 20s, and hypothyroidism diagnosed at an unknown time FH: family history of breast cancer (mother had lumpectomy) SH: smoked 2 pack years 22 years ago. Previous alcohol use – stopped 6 months ago. ROS: Only positive findings are seen in HPI Physical Exam: VS: Pulse – 72; BP – 116/68, RR – 16; T – 98.4F (37 C); SpO2 – 98% Breast: breasts appear normal and symmetrical w/o dimpling or nipple/areolar erosion or discharge. On palpation breasts are nontender, and no nipple blood or discharge evoked by exam.  Right breast shows a 2.5cm mass palpable in the upper-inner quadrant at 2o-clock position, no skin fixation or inflammation  Right breast also shows a second 2.0cm lesion palpable at 12o-clock position, no skin fixation or inflammation  Left Breast: WNL Lymphatic: 1.0cm Right axillary lymph node is firm, but mobile. Remaining lymph node assessment is negative. Abdomen: Abdomen mildly obese; nondistended ASSESSMENT/PLAN Test Results:  Diagnostic Mammography: Highly suspicious of breast cancer. o Right breast: 3cm mass in upper inner quadrant @ 2-o-clock position o Right breast: 1cm mass in the 12-o-clock position o Right breast: 1cm deeper mass in the 12-o-clock position o No left breast abnormality seen  Breast and Lymph node biopsy: o Breast mass: Invasive ductal carcinoma: ER-positive, PR-positive, HER2/neu-negative o Right-axillary lymph node: metastatic breast adenocarcinoma [Show More]

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