NUR 602 Renata Chapman Case Study 2022

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