IDENTIFYING DATA:

• Date & Time: 4/20/23 11:20 am
• Full Name: P. S.
• Address: ———
• DOB: –/–/99
• Location: Queens Hospital Center
• Source of information: self
• Reliability: reliable

 

CHIEF COMPLAINT: breast lump x 1 year

HISTORY OF PRESENT ILLNESS:

23 y/o G1P0010 female presents for annual exam c/o left breast lump x 1 year. Patient states she does not experience any changes to lump in regard to menstrual cycle. Patient reports she had breast reduction surgery in Jan 2022 and first noticed breast lump Mar 2022. Patient reports she has done at home breast exams and notices the lump is mobile and has not changed in size over the past year. Positive familial history of breast cancer with maternal grandmother, dx age 60. Patient denies pain, tenderness, nipple discharge, axillary tenderness, skin changes, rash.

Patient also complains of vaginal itching x 3 days. Reports she noticed odorless white clumpy discharge occasionally over past few days. Patient admits to multiple episodes of unprotected sex over the past month with one male sexual partner. Patient states she visited an outside GYN clinic 2 weeks ago and was diagnosed with cervicitis, s/p doxycycline and ceftriaxone treatment. As per pt she received HSV swab, results were negative, did not bring records with her today.  Denies fever, chills, dysuria, hematuria, urinary urgency/frequency, dyspareunia, abdominal pain, vaginal bleeding, nausea, vomiting.

LMP: 04/06/2023, q monthly, regular, 3-5 days

Patient counseled and declines contraceptives at this time.

 

Differential Diagnosis:

Breast lump –

• Fibroadenoma: The most common breast tumor in women < 30 yrs. Higher incidence in African Americans. Non tender and freely mobile.
• Fat necrosis of breast: patient has a past history of breast surgery. Fat necrosis is a benign condition where the fat tissue of the breast is damaged by surgery, injury, radiation, etc.
• Fibrocystic changes: masses do not change in relation to menstruation. No axillary lymph node involvement.
• Breast cancer: unlikely due to young age. Patient has + hx of family breast cancer. Breast mass is not fixed.

 Discharge –

• Candidiasis: pt complains of vaginal itching and white clumpy discharge. Patient also recently finished antibiotic course.
• Chlamydia: patient had recent dx of cervicitis, if partner was untreated for STI, possible to have reinfection.
• Gonorrhea: see above
• Bacterial vaginosis: pt complains of discharge, however discharge is odorless, making this dx less likely.

 

MEDICAL HISTORY:

Medications:

• No current medication use.
• Denies OTC or herbal supplement use

Medical History:

• Chlamydia – June 2019, treated
• Patient denies medical problems

Immunization Hx:

• Gardasil – completed series 10/19
• Declines influenza vaccine
• Declines COVID vaccine

Surgical History:

• Breast reduction surgery 1/2022 – patient unable to recall surgeon name
  • No complications
• Cystoscopy with lithotripsy laser, ureteroscopy, left stent placement 5/19/2021
  • Surgeon: Isuru Sampath Jayarantna, MD
  • Location: QHC
  • No complications
• Dilation and curettage 2/15/20 – patient unable to recall surgeon name
  • No complications

Allergies:

• No known drug allergies
• No known food allergies
• No known environmental allergies

Family History:

• Mother: alive & well, no significant PMHx
• Father: alive & well, hx HTN
• Maternal grandmother: alive, hx HTN, breast cancer dx age 60

Social History:

• Nonsmoker
• Admits to social alcohol use 1-2x per month
• Denies illicit drug use
• Occupation: student
• Caffeine: Denies caffeine use.
• Marital history: Single
• Home situation: living in apartment mother and 1 sister
• Diet: patient reports vegan diet
• Exercise: patient reports gym visits 3x per week 

OB History:

• G1P0010
  • Pregnancy outcomes:
    • #1: TOP – D&C @ 7 weeks 2/15/20, no complications

GYN/Sexual history:

• Menarche: age 12
• Menstrual cycle: regular, lasts 3-5 days avg
• LMP: 04/06/23
• Pap performed today; previous pap 4/22 nml
• Sexually active with 1 male partner.
• Contraception: Reports condom use, happy with use. Declines oral or other contraceptive forms.
• History of + Chlamydia treated 2019

 

ROS:

• General: Denies recent weight loss, changes in appetite, weakness, fatigue, fever, chills.
• Skin, hair, nails: Denies discolorations, pigmentations, moles/rashes, changes in hair distribution or texture, pruritus.
• Head: Denies headaches, vertigo or head trauma.
• Eyes: Denies blurred vision, photophobia, or changes in vision.
• Ears: Denies pain, discharge, or changes in hearing.
• Nose/sinuses: Denies discharge, congestion, and epistaxis.
• Mouth/throat: Denies bleeding gums, sore throat, mouth ulcers, voice changes.
• Neck: Denies localized swelling/lumps or stiffness/decreased range of motion.
• Breast: Admits to left breast lump x 1 year. Denies nipple discharge or pain.
• Pulmonary system: Denies dyspnea, cough, wheezing, and dyspnea on exertion.
• Cardiovascular system: Denies history of HTN, chest pain, syncope, palpitations, hx of known heart murmur.
• Gastrointestinal system: Has regular bowel movements daily. Denies constipation, diarrhea, bloody stool, nausea, vomiting, and hemorrhoids.
• Genitourinary system: Denies dysuria, incontinence, urinary frequency.
• Menstrual/Obstetrical – See OB/GYN hx and HPI above.
• Nervous: Denies loss of strength, seizures, loss of consciousness.
• Musculoskeletal system: Denies muscle/joint pain, deformity or swelling, redness or arthritis.
• Peripheral vascular system: Denies intermittent claudication, peripheral edema.
• Hematological system: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.
• Endocrine system: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.
• Psychiatric: Denies depression, anxiety, hx of seeing mental health professional.

 

PHYSCIAL:

General: AAO x 3. Appears stated age.

 Vitals:

• BP: 115/73
• Pulse: 70, regular
• Temp: 97.6 oral
• Wt: 134 lb
• Ht: 66 in
• BMI: 23.74 kg/m²
• LMP: 4/06/2023

Skin/Hair/Nails: Skin nonicteric, no lesions noted, no tattoos. Hair average quantity and distribution. No clubbing of nails.

HEENT: Head normocephalic, atraumatic. Eyes and ears symmetrical and appropriate in size OU. No discharge or foreign bodies on external auditory canals AU. Nares patent. Good dentition, no obvious dental caries noted. No gingival hyperplasia or erythema noted. Pharynx non-erythematous, with no exudates, uvula midline. No lesions noted.

Neck: Trachea midline. Supple; non-tender to palpation. FROM. No cervical adenopathy noted.

Thyroid: Non-tender; no palpable masses or nodules; no thyromegaly.

Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Chest: Symmetrical, no deformities, no trauma. Respirations unlabored, no use of accessory muscles noted.

Lungs: Clear to auscultation bilaterally, no adventitious sounds noted. Chest expansion and diaphragmatic excursion symmetrical.

Abdomen: Abdomen flat and symmetric, no striae noted. Bowel sounds normoactive in all four quadrants. Non-tender to palpation, no guarding or rebound noted. No CVA tenderness appreciated.

Breast: Left breast: No dimpling of skin. 3 cm hard, non-tender, mobile mass at 12:00, 2 cm from areolar border. Nipple without discharge or lesions.

Right breast: No dimpling, no masses to palpation. Nipple without discharge or lesions.

Axilla: no palpable axillary nodes

Female Genitalia: External genitalia without erythema or lesions. Vaginal mucosa pink with white clumpy discharge noted. Cervix pink and without lesions. No cervical motion tenderness. Uterus anterior, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear obtained.

Rectal: Deferred.

Extremities: No cyanosis, edema or deformities. No tenderness to calves. FROM.

Neurologic: Strength and sensation intact. GCS = 15.

 

ASSESSMENT:

23 y/o G1P0010 here for annual c/o 3 cm nontender, mobile LEFT breast mass located at 12:00 x 1 year. Patient is 2 weeks s/p cervicitis diagnosis, treated with doxycycline and ceftriaxone c/o vaginal itching with white clumpy discharge x 3 days.

 

PLAN:

#Annual

• Perform pap smear
• GC/Chlamydia testing
• Urine pregnancy test

#Candidiasis

• Diflucan 150 mg PO once

#Breast mass

• B/L breast sono to be scheduled
• Televisit 1 week post ultrasound to discuss results