A 27-Year-Old with a Palpable Breast Lump and Family History of Breast Cancer: A Case of Fibroadenoma

A 27-Year-Old with a Palpable Breast
Lump and Family History of Breast
Cancer: A Case of Fibroadenoma




## PATIENT DEMOGRAPHICS
- **Name:** Alexandra Mendoza
- **Age/Sex:** 27-year-old female
- **Reason for Encounter:** Breast problem
- **Setting:** Outpatient women's health / primary care clinic

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## CHIEF COMPLAINT (Patient's Own Words)
*"I found a lump in my right breast about two weeks ago. It hurts,
especially before my period. I'm really scared because my grandma had
breast cancer."*


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## HISTORY OF PRESENTING ILLNESS (HPI) – OLDCARTS Framework


| Component | Details |
|-----------|---------|
| **Onset** | Noticed lump ~2 weeks ago while performing breast self-
exam in the shower |
| **Location** | Right breast, upper outer quadrant |
| **Duration** | Lump is persistent; pain fluctuates with menstrual
cycle |
| **Character** | Smooth, round, rubbery, movable, well-
circumscribed, ~1–2 cm (grape-sized) |
| **Aggravating Factors** | Premenstrual phase, direct palpation |
| **Relieving Factors** | Pain improves after menstruation begins |
| **Timing** | Pain is cyclic (several months of bilateral breast
tenderness before menses); lump is constant |

, | **Severity** | Pain 3/10; Anxiety 9/10 |


**Additional History:**
- Denies nipple discharge, skin dimpling, erythema, warmth, or palpable
axillary lymph nodes
- No history of breast trauma, fever, chills, weight loss, night sweats, or
fatigue
- Significant anxiety related to family history of breast cancer (paternal
grandmother diagnosed at age 62)


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## PAST MEDICAL HISTORY (PMH)
- No chronic medical conditions
- No prior surgeries
- No hospitalizations
- No history of breast disease or prior breast biopsies
- No prior mammograms


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## MEDICATIONS