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 O t h e r a c t i v e p r o b l 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 M e d i c a l , s u r g i c a l , o b s t e t r i c , h o s p i t a l i z a t i o n s : 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 r e v e n t i v e H e a l t h : Full childhood vaccinations Exercise: None; sedentary Diet: Predominantly fast foods aunt junk food per patient's account I m m u n i z a t i o n s : 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 This study source was downloaded by from CourseH on :55:36 GMT -05:00 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 S k i n / B r e a s t : Negative---did not feel anything prior to mammographic finding H E E N T & N e c k : Negative C a r d i o v a s c u l a r : Negative R e s p i r a t o r y : Negative A b d o m e n / G a s t r o i n t e s t i n a l : Negative G e n i t o u r i n a r y : Negative M u s c u l o s k el e t a l : Negative N e u r o l o g i c a l : Negative A l l e r g i c / I m m u n o l o g i c : Negative L y m p h a t i c / E n d o c r i n e : Negative H e m a t o l o g i c : Negative P s y c h o l o g i c a l : Negative Vital signs: Temp: 98.6F Pulse: 70, rhythm: Regular BP: Left 116/70 Respiration: 16, effort: unlabored Physical exam: 148.0 pounds S k i n / B r e a s t : deferred on this follow-up visit