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July 23, 2020

Donna B. is a 45 year old peri-menopausal married woman

ASSIGNMENT INSTRUCTIONS
Donna B. is a 45 year old peri-menopausal married woman who home schools her 3 children ages 6, 10 and 14.

Chief Complaint: “I felt at lump in my right breast this morning while in the shower.”

Additional quotes: “I’m so scared” “It seems everything is going wrong.” “My husband is seeing another woman and I am so “fat”. What will happen to my 3 kids if this is cancer?”

SUBJECTIVE:Develop an HPI for Donna. Include all pertinent data using PQRSTU. Complete a problem focused history, family history, OB?GYN history and ROS based on the facts as you know them and use your imagination to fill in the blanks. Consider her emotional state.

OBJECTIVE: Complete a simulated focused physical examination. Use your imagination. Remember this is a focused exam related to the HPI. Describe your findings. Is there a lump? if so where on the breast? How does it feel? What about the rest of the breast tissue? Complete the exam findings of the breast with description of lymph nodes. Do you think other body systems should be examined? If so describe your findings? Don’t forget to assess her mental state.

As you write up this exam be sure to us medico-legal terminology. Submit the narrative write up as an attachment on the assignment page.

Remember this is a focused exam.

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