1
Breast Assessment
Pt. Initials: I.P
Gender: F
Age: 29
S: (CC, HPI, PMH, FH, SH, ROS)
CC: “Itchiness with redness around nipple and arm pit.”
HPI: Mrs. P is a 29-year-old female with no significant past medial history, who presents
today complaining of redness and itchiness of bilateral nipple and axilla for the past 2
weeks. Mrs. P denies any recent trauma, procedures, lumps or swelling to the
breast/chest area. She performs a self-breast exam monthly for the past 16 years. She
does state that she has recently began using a new detergent on some clothing.
PMH: Cholecystitis with Cholecystectomy-2009, wisdom teeth extraction-2011; UTD
immunizations- most recent flu vaccine- October 2016.
FH: Denies any family history of breast, uterine, or ovarian cancer.
Paternal-Grandfather: Deceased, DM 84 you
Paternal-Grandmother: Deceased, cancer-unknown 70 y.o.
Maternal-Grandfather: Deceased, COPD 86 y.o.
Maternal-Grandmother: Deceased, CHF 62 y.o.
Mother: Living, DM, hypothyroidism 61 y.o.
Father: Living, HTN, arthritis 64 y.o.
SH: Denies history or current ETOH intake, smoking or illicit drug use. Married, no
children. Currently active vegan diet with supplemental protein shakes. Currently works
as RN on bone marrow cancer unit at Jewish Hospital.
ROS: No fever, malaise, or fatigue. VSS, Ht-5’2” Wt-170 lbs. BMI-28.3
Breasts: Positive for redness around bilateral nipple and axilla. Complains of itching at
sites of redness. Denies pain, lumps, discomfort, or nipple discharge. Performs self-
breast exams monthly x 15 years. Denies prior mammogram, ultrasound of breasts.
Genitourinary: LMP: 8/4/2017; Denies taking any birth control currently. Last pap:
2/2016; Denies vaginal drainage, bleeding between menses.
Skin/Hair/Nails: Positive for rash and itching around bilateral nipple and bilateral axilla.
Breast Assessment
Pt. Initials: I.P
Gender: F
Age: 29
S: (CC, HPI, PMH, FH, SH, ROS)
CC: “Itchiness with redness around nipple and arm pit.”
HPI: Mrs. P is a 29-year-old female with no significant past medial history, who presents
today complaining of redness and itchiness of bilateral nipple and axilla for the past 2
weeks. Mrs. P denies any recent trauma, procedures, lumps or swelling to the
breast/chest area. She performs a self-breast exam monthly for the past 16 years. She
does state that she has recently began using a new detergent on some clothing.
PMH: Cholecystitis with Cholecystectomy-2009, wisdom teeth extraction-2011; UTD
immunizations- most recent flu vaccine- October 2016.
FH: Denies any family history of breast, uterine, or ovarian cancer.
Paternal-Grandfather: Deceased, DM 84 you
Paternal-Grandmother: Deceased, cancer-unknown 70 y.o.
Maternal-Grandfather: Deceased, COPD 86 y.o.
Maternal-Grandmother: Deceased, CHF 62 y.o.
Mother: Living, DM, hypothyroidism 61 y.o.
Father: Living, HTN, arthritis 64 y.o.
SH: Denies history or current ETOH intake, smoking or illicit drug use. Married, no
children. Currently active vegan diet with supplemental protein shakes. Currently works
as RN on bone marrow cancer unit at Jewish Hospital.
ROS: No fever, malaise, or fatigue. VSS, Ht-5’2” Wt-170 lbs. BMI-28.3
Breasts: Positive for redness around bilateral nipple and axilla. Complains of itching at
sites of redness. Denies pain, lumps, discomfort, or nipple discharge. Performs self-
breast exams monthly x 15 years. Denies prior mammogram, ultrasound of breasts.
Genitourinary: LMP: 8/4/2017; Denies taking any birth control currently. Last pap:
2/2016; Denies vaginal drainage, bleeding between menses.
Skin/Hair/Nails: Positive for rash and itching around bilateral nipple and bilateral axilla.
