History and Physical and Labs
(Translation of shorthand is in italics)
CC (Chief complaint): Breast lump
HPI (History of present illness): SM is a 61-year-old woman who presents to her
internist alarmed by a lump in her right breast that she discovered while showering. She
does not report any pain, swelling, or skin changes. She has not experienced fever,
weight loss, headache, nausea, vomiting, dizziness, or bone pain.
PMH (past medical history): SM is moderately overweight, but otherwise in good
health. Her last mammogram, which was normal, was 2 years ago. She experienced
menarche at age 10, had her first and only child at age 36, and experienced menopause at
age 55. She took hormone replacement therapy from age 54 until age 59.
FH (family history): No history of malignancy in first-degree relatives. SM has one
sister, age 58, who is in good health.
SH (social history): SM is married and is a university history professor. She has a
grown daughter who lives nearby. She has never smoked and drinks no more than two
alcoholic drinks per week. She does not perform breast self-exams.
Physical Exam:
VS (vital signs): T=98.2 HR (heart rate)=70
pressure)=130/90
RR (respiration rate)=15
BP (blood
HEENT (Head, Ears, Eyes, Nose, Throat): Normal
Neck: No JVD, no lymphadenopathy, strong carotid pulses, no bruits
Lungs: clear to auscultation bilaterally
Heart: RRR (regular rate and rhythm), S1/S2 normal, no murmurs, rubs, or gallops ( =
normal heart sounds, rate and rhythm)
Abdomen: moderately obese, soft, non-tender, non-distended, normal bowel sounds, no
hepatosplenomegaly (hepato = liver; spleno = spleen; megaly = enlarged), no masses.
Extremities: warm, well-perfused
Neuro: A&Ox3 (alert and oriented to person, place and time), CNII=XII grossly intact.
Reflexes normal and symmetric. Strength, sensation normal.
Breast/axilla: No visible abnormalities on sitting or supine exam. L breast and axilla
normal. R breast with ~2 cm hard, immobile lesion with irregular borders, in superior
lateral quadrant approx. 6 cm from areola. No palpable axillary or supraclavicular lymph
nodes.
Laboratory results:
Liver function tests normal.
Why order LFTs? An elevated alkaline phosphatase is an indication for a liver ultrasound
for possible metastases. Other surveillance for metastases (bone scans, head CT, chest XRay, are not indicated in the absence of symptoms).