19 Feb A 32-year-old woman presents for evaluation of a lump that she noticed in her right breast on self-examination
Case Study: A 32-year-old woman presents for evaluation of a lump that she noticed in her right breast on self-examination. She says that while she does not perform breast self-examination often, she thinks that this lump is new. She denies nipple discharge or breast pain, although the lump is mildly tender on palpation. She has never noticed any breast masses previously and has never had a mammogram. She has no personal or family history of breast disease. She takes oral contraceptive pills (OCPs) regularly, but no other medications. She does not smoke cigarettes or drink alcohol Links to an external site.. She has never been pregnant. On examination, she is a well-appearing, somewhat anxious, and thin woman. Her vital signs are within normal limits. On breast examination, in the lower outer quadrant of the right breast, there is a 2-cm, firm, well-circumscribed, freely mobile mass without overlying erythema that is mildly tender to palpation. There is no skin dimpling, retraction, or nipple discharge. While no other discrete breast masses are palpable, the bilateral breast tissue is noted to be firm and glandular throughout. There is no evidence of axillary, supraclavicular, or cervical lymphadenopathy. The remainder of her physical examination is unremarkable.
NGR6002C – SOAP Note 2 – 4 Rubric (1)
