cause. Physical exam shows 2 palpable breast masses, one 2.5cm mass in the upper quadrant of

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:

• 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.