NSG 6430 SU_NSG6430_W2_A2_Trehern_H.

Name: A.T. Date: 11/01/22 Time: 1649 Age: 77 Sex: F SUBJECTIVE CC: “Last week I noticed a lump in my breast while I was doing a self-breast exam in the shower. It doesn’t hurt and hasn’t changed in size since I first felt it. You can feel it right here.” HPI: Patient presents with reports of non-tender, non-mobile mass she palpated in her right breast 7 days ago. Mass is consistently palpable; does not come and go or change in size. No aggravating or alleviating factors. No redness, streaking, or warmth. Patient denies nipple retraction or discharge. Last mammogram Oct 2021 which showed fibrocystic changes- otherwise normal. Total hysterectomy approximately 40 years ago. Patient has no past or presents known history of breast cancer, has never used hormonal therapy. Medications: atorvastatin 40 mg daily for hyperlipemia, diogoxin 125 mcg daily for heart failure, furosemide 40 mg daily for heart failure, insulin aspart (NovoLog) 100 unit/ml PRN SQ on sliding scale for diabetes, insulin glargine (Lantus) 100 unit/ml SQ- 25 Units in AM and in PM for diabetes, Potassium Chloride 10mEq po bid with food to replace potassium lost from Lasix, aspirin 81mg daily for heart disease PMH Allergies: No known allergies Medication Intolerances: No known medication intolerances Chronic Illnesses/Major traumas: diabetes, heart disease, heart failure, hyperlipidemia, history symptomatic bradycardia caught on loop recorder in 2008, history of fibrocystic breast disease