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Female Genitourinary, & Musculoskeletal

What other subjective data would you obtain?
What other objective findings would you look for?
What diagnostic exams do you want to order?
Name 3 differential diagnoses based on this patient presenting symptoms?
Give rationales for your each differential diagnosis.
What teachings will you provide?

case study #1
Female Genitourinary, & Musculoskeletal
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
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

Full Answer Section

Nipple Changes:
- Specifically ask about any nipple discharge (color, consistency, spontaneous or expressed, unilateral or bilateral), even if she initially denies it. Sometimes patients may not consider clear discharge as significant.
- Any inversion, retraction, scaling, or rash of the nipple/areola?
Skin Changes:
- Any specific skin changes over the breast/lump (e.g., dimpling, puckering, rash, redness, warmth, "peau d'orange" appearance)? She denies skin changes, but I'd ask specifically for details.
Systemic Symptoms (Constitutional Symptoms):
- Any unexplained weight loss or gain?
- Night sweats?
- Fatigue beyond normal levels for her profession?
- Appetite changes?
Pain Assessment:
- Any breast pain (mastalgia) that is cyclical or non-cyclical, unilateral or bilateral? Location, intensity, character (dull, sharp, aching), radiation?
Family History (More Detail):
- Grandmother's Breast Cancer: What type of breast cancer was it (if known)? Was it unilateral or bilateral? What was her age at diagnosis (already provided as 76, which is typically considered late-onset)?
- Other Family Members: Any other first-degree relatives (mother, sisters, daughters) with breast cancer? Any second-degree relatives (aunts, nieces, paternal grandmother) with breast cancer? Any family history of ovarian, prostate, or pancreatic cancer, or male breast cancer (which might suggest a genetic predisposition like BRCA)? At what age were these diagnoses made?
- Ashkenazi Jewish Ancestry: Given her African American ethnicity, also ask about Ashkenazi Jewish heritage, as this population has a higher prevalence of BRCA mutations.
Reproductive History:
- Age of menarche (first period)?
- Number of pregnancies (gravida) and live births (para)?
- Age at first full-term pregnancy? (Nulliparity or first full-term pregnancy after age 30 increases risk).
- Duration of breastfeeding (if applicable)?
Other Risk Factors:
- Alcohol Intake: Quantity and frequency.
- Smoking History: Current or past? Pack-years?
- Previous Breast Biopsies/Lumps: History of benign breast disease (e.g., atypical hyperplasia, lobular carcinoma in situ (LCIS), ductal carcinoma in situ (DCIS) – these are significant risk factors for invasive cancer).
- Radiation Exposure: History of radiation to the chest (e.g., for Hodgkin's lymphoma at a young age)?
- Diet and Exercise: General dietary habits and exercise routine (related to BMI, which is already 24, a healthy weight).
Psychosocial Impact:
- How is she coping with this finding? What are her fears or concerns?
- Does she have a support system?

Sample Answer

Patient: R.K., 55-year-old African American female, social worker Chief Complaint: "I have a tumor on my left breast." Key Finding: 5-mm nonmobile, non-tender, firm mass felt at 10 o'clock position, 5 cm from the areola in the left breast.

1. What other subjective data would you obtain?

To gain a more complete picture and narrow down the differential diagnoses, I would obtain the following additional subjective data:

Lump Characteristics:
- Onset: When exactly did she first notice it? Was it sudden or gradual?
- Change Over Time: Has its size, shape, or consistency changed since she first noticed it? Has it grown?
- Associated Symptoms: Any pain or tenderness now or previously in the lump or breast? Any itching, warmth, or redness of the skin over the lump?
- Relationship to Menstrual Cycle (even post-menopause): While s