K.F., 38yo, F, Caucasian and Latino
S.
CC- fatigue, right breast pain, vaginal itching
HPI- The breast pain is in the right breast and now into the right axilla. It is warm and tender to
touch. She has not noticed any nipple discharge. She has also had mild myalgia. The vaginal
itching began a few days before the breast pain. She reports a great deal of stress. She has not
been monitoring for a fever. She denies diarrhea or constipation, abdominal pain, skin changes,
cough, or chest pain. She has not been sleeping well, due to having to stay with her daughter in
the hospital. No recent physical or well woman exam since the birth of her son. She has not had
dysuria. LNMP was 6 weeks ago, 8 days in length, heavy for 5 days with clots. Menses are
irregular, having only 5 to 6 per year.
PMH- No surgical history other than cesarean sections; no trauma history; 10 year 1PPD
smoker, smoking cessation 2 years ago; gestational diabetes with last pregnancy; history of
PCOS. Gravidity and Parity: G:4, T:2, P:1, A:1, L:3.
Social History- She continues to live with her parents during a separation from her husband and
is working part time at the children’s school library but has not been there for over a week. She
has no health insurance, but her children are now covered by the State Medicaid HMO.
Family History- Her paternal great grandmother died of breast cancer at the age of 50. Her
mother has hypertension, hyperlipidemia, and type 2 diabetes. Her father has hypertension,
hyperlipidemia, and cardiovascular disease.
ROS-
Constitutional- Reports mild myalgia.
Skin- Right breast pain with warmth and tender to touch. Denies any other skin changes.
Cardiovascular- Denies chest pain.
Respiratory- Denies cough.
Gastrointestinal- Denies any diarrhea, constipation, abdominal pain.
Genitourinary- Vaginal itching x a few days.
Neurological- None reported
Musculoskeletal- Mild myalgia.
Hematologic- None reported.
, Psychiatric- Under a lot of stress.
Endocrinologic- None reported
Allergies- NKA
O.
Vital Signs: Height: 160cm Weight: 70 kg, B/P:120/62, T: 99.2, HR: 100, Resp: 16, reg, non-
labored, SpO2: 99%. BMI: 27.34 (Overweight)
General: Awake, alert, appropriate; well groomed; skin: warm, dry, intact. HEENT: Head
normocephalic. Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic membranes
intact, unremarkable; nares patent, unremarkable bil; pharynx unremarkable tonsils 2/4 bil; neck
supple w/o lymphadenopathy.
Breast Exam: Tanner IV female with large pendulous breasts bil. No nipple discharge. No
nodules. Tenderness and erythema in a 6cm oval area to the right breast in the upper outer
quadrant and into the tail of Spence. Right axilla lymphadenopathy noted.
Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and
unlabored; abdomen, soft, with normoactive bowel sounds throughout.
Abdomen: Normoactive bowel sounds throughout; tenderness to palpation in the super-pubic
area; no masses or organomegally; peripheral pulses reg., equal, intact; pelvic exam reveals sl.
injected vaginal mucosa with a moderate whitish discharge. Erythema to the inside of the labia
minora also noted.
Urinalysis in the office: Cloudy amber yellow urine, Sp. Gr. 1.010, positive WBCs, nitrites, and
leukoesterase; negative for RBCs, glucose, and ketones.
Wet mount: Positive for Spores, Hyphae and clue cells.
A.
Primary Diagnosis:
Mastitis (91.22)- Mastitis is a swelling of the breast that is usually caused by an infection.
Women with mastitis may have pain with a tender, red, wedge-shaped area on the breast. They
may also have fever and chills, or they may feel tired and sick (AFP, 2016). Kayla is having right
breast tenderness that is now spreading to the axilla.
Secondary Diagnoses:
Urinary tract infection (N39.0) – an infection of the urinary tract, symptoms include; dysuria,
frequency, urgency and suprapubic or flank discomfort, and in some women they are only tired
S.
CC- fatigue, right breast pain, vaginal itching
HPI- The breast pain is in the right breast and now into the right axilla. It is warm and tender to
touch. She has not noticed any nipple discharge. She has also had mild myalgia. The vaginal
itching began a few days before the breast pain. She reports a great deal of stress. She has not
been monitoring for a fever. She denies diarrhea or constipation, abdominal pain, skin changes,
cough, or chest pain. She has not been sleeping well, due to having to stay with her daughter in
the hospital. No recent physical or well woman exam since the birth of her son. She has not had
dysuria. LNMP was 6 weeks ago, 8 days in length, heavy for 5 days with clots. Menses are
irregular, having only 5 to 6 per year.
PMH- No surgical history other than cesarean sections; no trauma history; 10 year 1PPD
smoker, smoking cessation 2 years ago; gestational diabetes with last pregnancy; history of
PCOS. Gravidity and Parity: G:4, T:2, P:1, A:1, L:3.
Social History- She continues to live with her parents during a separation from her husband and
is working part time at the children’s school library but has not been there for over a week. She
has no health insurance, but her children are now covered by the State Medicaid HMO.
Family History- Her paternal great grandmother died of breast cancer at the age of 50. Her
mother has hypertension, hyperlipidemia, and type 2 diabetes. Her father has hypertension,
hyperlipidemia, and cardiovascular disease.
ROS-
Constitutional- Reports mild myalgia.
Skin- Right breast pain with warmth and tender to touch. Denies any other skin changes.
Cardiovascular- Denies chest pain.
Respiratory- Denies cough.
Gastrointestinal- Denies any diarrhea, constipation, abdominal pain.
Genitourinary- Vaginal itching x a few days.
Neurological- None reported
Musculoskeletal- Mild myalgia.
Hematologic- None reported.
, Psychiatric- Under a lot of stress.
Endocrinologic- None reported
Allergies- NKA
O.
Vital Signs: Height: 160cm Weight: 70 kg, B/P:120/62, T: 99.2, HR: 100, Resp: 16, reg, non-
labored, SpO2: 99%. BMI: 27.34 (Overweight)
General: Awake, alert, appropriate; well groomed; skin: warm, dry, intact. HEENT: Head
normocephalic. Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic membranes
intact, unremarkable; nares patent, unremarkable bil; pharynx unremarkable tonsils 2/4 bil; neck
supple w/o lymphadenopathy.
Breast Exam: Tanner IV female with large pendulous breasts bil. No nipple discharge. No
nodules. Tenderness and erythema in a 6cm oval area to the right breast in the upper outer
quadrant and into the tail of Spence. Right axilla lymphadenopathy noted.
Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and
unlabored; abdomen, soft, with normoactive bowel sounds throughout.
Abdomen: Normoactive bowel sounds throughout; tenderness to palpation in the super-pubic
area; no masses or organomegally; peripheral pulses reg., equal, intact; pelvic exam reveals sl.
injected vaginal mucosa with a moderate whitish discharge. Erythema to the inside of the labia
minora also noted.
Urinalysis in the office: Cloudy amber yellow urine, Sp. Gr. 1.010, positive WBCs, nitrites, and
leukoesterase; negative for RBCs, glucose, and ketones.
Wet mount: Positive for Spores, Hyphae and clue cells.
A.
Primary Diagnosis:
Mastitis (91.22)- Mastitis is a swelling of the breast that is usually caused by an infection.
Women with mastitis may have pain with a tender, red, wedge-shaped area on the breast. They
may also have fever and chills, or they may feel tired and sick (AFP, 2016). Kayla is having right
breast tenderness that is now spreading to the axilla.
Secondary Diagnoses:
Urinary tract infection (N39.0) – an infection of the urinary tract, symptoms include; dysuria,
frequency, urgency and suprapubic or flank discomfort, and in some women they are only tired
