NR 602 Week 1 iHuman Case 1 – Physical Exam (Renata Chapman) 2026/2027) (8pages)

Renata Chapman 42-year-old female Height 5’5 (165 cm) Weight 149.0 lb (67.7 kg) Chief complaint: Two right-breast lumps Skin: warm, dry HPI (History of present illness): Name: Renata Chapman Age: 42 years Sex: F Height: 5' 5" (165.0 cm) Weight: 149 lb (68.0 kg) (BMI 24.8) Temperature: 98.4 F (oral) Pulse: 72 bpm - regular Blood pressure: 116/68 mmHg - supine/sitting Blood pressure: 102/62 mmHg - upon standing Respiratory rate: 16 bpm SpO2: 98% on room air PMH (Pervious medical history): Allergies: None Oth er a cti ve p ro bl e m s : Right-ovarian hemorrhagic cyst (spontaneously resolved): year unknown Chronic idiopathic pancreatitis: diagnosed in her 20s Hypothyroidism: age at time of diagnosis not recalled Me dical , surgical , obst et ri c, hospit a li zatio ns: OB/GYN: Menarche age 14; G2P2; first pregnancy at age 25 vaginal; second at age 32 C-section 7 years ago, follow by a bilateral tubal ligation (BTL) P re ve ntiv e He a lth : Full childhood vaccinations Exercise: None; sedentary Diet: Predominantly fast foods aunt junk food per patient's account Immuniza tio ns: Immunizations: none in the last 7 years Completed childhood-vaccination schedule Medications: Levothyroxine 25 mcg one tablet daily Pancrelipase 15000 units two tablets before each meal and snack Oxycodone 5 mg one tablet every four hours as needed Amitriptyline 25 mg one tablet daily Family History: Mother: alive; breast cancer diagnosed at age 48 (lumpectomy, no known recurrence) Father: alive and healthy Siblings: none Social History: Occupation: Disabled due to chronic pancreatitis Marital status: Never married; lives with her two children Sexual history: Not sexually active for the last 5 years; negative HIV test sometime within the last 7 years Alcohol use: Two glasses of wine a day starting at 18 years of age; none for six years Tobacco use: Less than one pack a day from 18-20 years of age; none since Illicit drugs: None/never ROS (Review of System): General/Constitutional: Negative Sk in/ Bre as t: Negative---did not feel anything prior to mammographic finding H EEN T & N e ck : Negative Cardiovasc ul ar: Negative Re s p i ra to ry : Negative Abd o me n/ G as tro i n te s t in al : Negative Ge nitouri nary: Negative M u s cu l os k e l e tal : Negative N e urol o gical : Negative Al l e rgic/ I mmu n o l o gic: Negative L y mp h a ti c/ E n d o cri ne : Negative He matol ogic: Negative Ps y ch o l o gical : Negative Vital signs: Temp: 98.6F Pulse: 70, rhythm: Regular BP: Left 116/70 Respiration: 16, effort: unlabored Physical exam: 148.0 pounds deferred on this follow-up visit Sk in/ Bre ast: H EEN T & Ne ck :