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For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your case number is 1

Case 1Case 2Case 3Chief Complaint

(CC)

“I have a tumor on my left breast”“I have pain during intercourse and urination”“My back hurts so bad I can barely walk”

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.A 19-year-old female reports to you that she has “sores” on and in her vagina for the last three months.A 35-year-old male painter presents to your clinic with the complaint of low back pain. He recalls lifting a 5-gallon paint can and felt an immediate pull in the lower right side of his back. This happened 2 days ago and he had the weekend to rest, but after taking Motrin and using heat, he has not seen any improvement. His pain is sharp, stabbing, and he scored it as a 9 on a scale of 0 to 10.

Drug Hx

I took birth control pills for 10 years, starting when I was 20 I am not on hormone replacementShe tries to practice safe sex but has a steady boyfriend and figures she doesn’t need to be so careful since she is on the birth control pill Motrin for pain.

Family Hx

My grandmother had breast cancer when she was 76 years old Father hypertension

Mother DM

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

states “I have sores and bumps on the inner creases of my thighs and pelvic area”. “There is yellowish discharge from the sores that comes and goes”He is having some right leg pain but no bowel or bladder changes. No numbness or tinglingObjective 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) 24temperature: 100.2°F; pulse 92; respirations 18; BP 122/78; weight 156 lbs, 25 lbs overweight; height 5?3?temperature: 98.2°F, respiratory rate 16, heart rate 90, blood pressure 120/60

O2 saturation 98%

General

well developed, nourished, healthy-appearing femalepatient appears to have good hygiene; minimal makeup, pierced ears, no tattoos; well nourished (slightly overweight); no obvious distress notedwell-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, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip.

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

Lungs

clear to auscultation

within normal limits, appropriate lung sounds auscultated, clear and equal bilaterally

CTA AP&L

Card

regular rate and rhythm (RRR)S1S2 without rub or gallopS1S2 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.

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 lymphadenopathyInguinal Lymph nodes: tenderness bilaterally, numerous, 1 cm in sizeno bruising, fever, or swelling noted, no acute bleeding or trauma to skin.

Abd

normoactive bowel sounds x 4;tender during palpation; the left lower quadrant was very tender during palpation; patient denies nausea or vomitingbenign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.

GU

Bladder is non-distended.labia major and minor: numerous ulcerations, too many to count; some ulcerations enter the vaginal introitus; no ulcerations in the vagina mucosa; cervix is clear, some greenish discharge; bimanual exam reveals tenderness in left lower quadrant; able to palpate the left ovary; unable to palpate the right ovary; no tenderness; uterus is normal in size, slight tenderness with cervical mobilityBladder is non-distended.

Integument

good skin turgor noted, moist mucous membranesintact without lesions masses or rashes.

MS

Muscles are smooth, firm, symmetrical. Full ROM. No pain or tenderness on palpation.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-XIINo obvious deficits and CN grossly intact II-XIIDTRs 2+ lower sensory neurology intact to light touch and patient able to toe and heel walk. Gait was stable and no limping noted.

Once you received your case number, answer the following questions:

What other subjective data would you obtain?

What other objective findings would you look for?

What diagnostic exams do you want to order?

Name 3 differential diagnoses based on this patient presenting symptoms?

Give rationales for your each differential diagnosis.

What teachings will you provide?

  
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