For this Discussion, you will take on the role of a clinician who is building a

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 instructor will assign you your case number.
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 I 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
General
well developed, nourished, healthy-appearing
female
HEENT
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva
and sclera clear, nares patent, nasopharynx clear, edentulous.
Lungs
clear to auscultation
Card
regular rate and rhythm (RRR)
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
Lymph
negative axillary, infraclavicular, and
supraclavicular lymphadenopathy
Abd
normoactive bowel sounds x 4;
GU
Bladder is non-distended.
Integument
good skin turgor noted, moist mucous
membranes
MS
Muscles are smooth, firm, symmetrical. Full
ROM. No pain or tenderness on palpation.
Neuro
No obvious deformities, CN grossly intact
II-XII
Once you received your case number, answer the following questions:
1. What
other subjective data would you obtain?
2. What
other objective findings would you look for?
3. What
diagnostic exams do you want to order?
4. Name 3
differential diagnoses based on this patient presenting symptoms?
5. Give
rationales for your each differential diagnosis.
6. What
teachings will you provide?
Submission Instructions:
·
Your initial post should be 500 words, formatted and cited
in current APA 7th style with support from at
least 3 academic sources.
·
Turnitin similarity should be less than 14%
·
Quotes “…” cannot be used at a higher learning level for your
assignments, so sentences need to be paraphrased and referenced.
·
Acceptable references include scholarly journal articles or
primary legal sources (statutes, court opinions), journal articles, and books
published in the last five years. No websites to be referenced without
prior approval.
Textbook(s)
1. Rhoads, J., Demler, T. L., & Dlugasch, L. (2021). Advanced health
assessment and
diagnostic reasoning (4th ed.). Jones & Bartlett Learning.
ISBN: 9781284170313