ADMITTING HISTORY/ PHYSICAL EXAMINATION

Patient: Mrs. Dee Age: 40 y/o Sex/CS: Female/ Married Ward/Bed No:_________

CHIEF COMPLAINT: Breast Tenderness and Nodularity PHYSICAL EXAMINATION

General survey: Mrs. Dee is a 40 year old woman who is awake, oriented in

HISTORY OF PRESENT ILLNESS: Mrs. Dee is a 40 year old housewife with a Chief date, time, and place. She experiences tenderness in her left breasts.

Complaint of Breast Tenderness and Presence of lump in her left breast as she felt it

while she’s taking a bath. Mrs. Dee described the tenderness as she positioned herself VITAL SIGNS: BP: 130/100 mmHg PR: 90 cpr

in left side lying position as she tries to sleeps. She complains aggravated pain when her RR: 22bpm T*: 37°C

left breast are accidentally hit. She then called by her doctor and advised her to have a

complete pre-operative work up, mammography, breast biopsy, hende admitted.

HEENT: Eyes: Able to move eyes in full range motion, no loss of vision, no

PAST MEDICAL HISTORY: Mrs. Dee was diagnosed with Benign Proliferative Breast protrusion of eyeballs. Ears: No lesion, no loss of hearing, and clear with minimal

Disease over the past year. There are no history of childhood illness. No history of cerumen. Nose: Nasal septum is straight. Mouth: Pinkish and moist, no swelling

allergies. Normal gag reflex and slightly hoarseness of voice.

Heart: Regular heart rate and rhythm. CR: 90 cpm

OB-GYNE HISTORY ___________________N/A________________________________ Chest/Lungs: no difficulty of breathing. Breast: Mrs. Dee complains unintentional

______________________________________________________________________ weight loss indicating the possible presence of breast cancer. Presence of lumps in

______________________________________________________________________ left breast. (Biopsy revealed adenocarcinoma)

Abdomen: soft, flat, bowel sounds present, no bruits. Non tender to palpation.

MENSTRUAL HISTORY: Her menarche is 10 years old, the interval of her period is 28 Liver edge, spleen, kidney not felt.

days, duration is 5 days, and the amount of her period is 3-4 pads per day, it is soaked Extremities: Upper: Symmetrical in color, warmth, presence of enlarged lymph

during her 2nd to 3rd day of her period. Nodes in the left axilla. Lower: legs are warm and dry with good muscle

contraction. No clubbing nor cyanosis.

FAMILY HISTORY: ____________________________________________________________________

(+) Hypertension GIT/ABDOMINAL: FUNDIC HEIGHT: N/A EFW: N/A

(+) Diabetes LEOPOLDS MANUEVER: N/A

Her aunt passed away from breast cancer Genito-Urinary N/A

External Genitalia N/A

PERSONAL/SOCIAL HISTORY: Speculum Exam N/A

Patient Dee is a 40 y/o, housewife, married with no kids, only walks herself in the Internal Exam N/A

Market every morning as her form of exercise. She doesn’t smoke or drink alcohol Clinical Pelvimetry N/A

but caught herself in 2nd hand smoke because of her husband’s smoking habits. Recto Vaginal Exam N/A

REVIEW OF SYSTEM Neurologic Exam

General: Mrs. Dee is awake and alert. She doesn’t have fever, fatigue or weakness. She I Can identify different aromas on each other side of the nose

complains breast tenderness and unintentional weight loss. II Able to see 50 degrees superiorly, 90 degree laterally and 70 degree inferiorly

HEENT Eyes: Able to move eyes in full range motions, no loss of vision, no protrusion III Able to follow fingers through all the six cardinal position of gaze

of eyeballs, appear equal in size when eyes are open. Ears: External canal is clear with IV Able to follow fingers through all the six cardinal position of gaze

minimal cerumen, no lesion and no loss of hearing. Nose: Nasal septum is straight. V Able to follow fingers through all the six cardinal position of gaze

Mouth: Pinkish and moist, no swelling, normal gag reflex & slightly hoarseness of voice. VI Able to feel equally on all areas, able to discriminate between dull and sharp

Cardiovascular: denies chest pain, no bulges on the chest, and no thrills. VII Able to identify various taste, facial muscle are symmetrical at rest

Skin/ Breast: Slight asymmetry of the breast, with the left nipple deviated laterally and VIII Able to repeat words spoken, negative Romberg, has a good balance

Superiorly and presence of lump in left breast. IX- X normal gag reflex, slightly hoarseness of voice, able to swallow w/out diff.

Gastrointestinal: Normal appearance flat, smooth and symmetrical. XI Able to shrug shoulder but there’s slight pain in her axillary because of lymph

Neurological: denies headache, muscle spasm, loss of consciousness, sensitivity. XII Able to move tongue without any difficulty

Musculoskeletal: No heat, tenderness, swelling or masses in the joints.

ADMITTING IMPRESSION : Malignant Breast Tumor