Name: Ms. F

Sex: Female

Address: Brooklyn, NY

Date of Birth: 8/28/1985, 36 years old

Date & Time: 10/21/21, 10:30 PM

Location: Woodhull Hospital Labor and Delivery Unit

Marital Status: Single

Race: African American

Source of Information: Self

Reliability: Reliable

Mode of Transport: Uber

Chief Complaint: “my breast hurts” x 5 days

History of Present Illness: 

36 y/o African American pregnant female G5P2022 @ 34 weeks gestation presents ℅ right sided breast pain x 5 days. Pt states pain is aching and pressure like, non-radiating, is constant, came on gradually and has been increasing in severity, currently rates pain as 10/10. Denies aggravating or alleviating factors, states she did not take anything to help with the pain. Admits to redness and swelling around the site of pain. States that she has had small abscesses to the skin in the past that self-resolved, however this episode is worse. Denies h/o trauma or fall, left breast pain, fever, chills, N/V, abdominal pain, weakness, decreased appetite, lethargy, CP, SOB, HA, or dizziness. 

Past Medical History:

Present medical illnesses – none

Past Illnesses- none

Childhood illnesses – none

Immunizations – Up to date

Screening Tests- none

Blood Transfusions- none

Past Surgical History: none

Medications:

1. Prenatal Multivitamins- Folic acid-iron, 27-.8 Mg tablet, 1 tablet PO, QD

Allergies:

No known food, drug, or environmental allergies.

Family History:

Mother – aged 58, hypertension

Father – aged 63, alive and well 

Son- age 8, alive and well, born at 39 weeks gestation, NSVD no complications

Son- age 2, alive and well, born at 38 weeks gestation, NSVD, no complications

Social History:

Mrs. H is a 54 y/o single female. She is currently unemployed. She lives at home with her mother and 2 sons. 

Habits – Patient drinks one cup of coffee every morning. Admits to smoking marijuana daily. Denies ETOH use, use of nicotine cigarettes, e-cigarettes or other illicit drug use. 

Travel- Denies any recent travel.

Safety- Admits to wearing seat belt.

Sleep – Admits to sleeping well, for about 7 hours every night.

Exercise – States that she walks about 30 minutes every day.

Diet- Patients maintains a balanced diet, including fruits and vegetables.

Sexual History: Monogamous, admits to being currently sexually active. Denies history of sexually transmitted infections.

OB Status: Pregnant, LMP was 4/01/2021 

Review of Systems:

General – Denies loss of appetite, recent weight loss or gain, current generalized weakness, fatigue, fever, chills, or night sweats.

Skin, hair, nails –Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies dizziness, headaches, vertigo or head trauma, unconsciousness, head fracture or coma.

Eyes – Denies visual disturbances, fatigue, lacrimation, photophobia, and pruritus. Last eye exam last January- normal.

Ears –Denies ear pain, discharge, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat – Denies sore throat, sore tongue, bleeding gums, mouth ulcers, voice changes. 

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Breast- Admits to redness, swelling, and pain in the right breast.

Pulmonary system – Denies dyspnea, shortness of breath, cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis or hemoptysis.

Cardiovascular system –  Denies chest pain, palpitations, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal system –Denies changes in appetite, intolerance to foods, abdominal pain, nausea, vomiting, diarrhea, constipation, dysphagia, pyrosis, eructation, jaundice, hemorrhoids, rectal bleeding, or blood in stool. 

Genitourinary system –Denies urinary frequency, urgency, polyuria, oliguria, nocturia, incontinence, dysuria, hesitancy, dribbling, or flank pain.

Musculoskeletal system – Denies muscle/joint pain, arthritis, deformity or swelling, or redness.

Nervous System–Denies seizures, loss of consciousness, ataxia, loss of strength, change in sensation/tingling/ numbness, change in cognition / mental status / memory, or asymmetric weakness.

Peripheral vascular system –  Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, or color changes.

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.

Endocrine system –Denies polyuria, polyphagia, polydipsia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric –Denies depression, anxiety, OCD or ever seeing a mental health professional.

 Physical Exam

General: 36 year old female, alert and oriented to person, place and time. Patient is of obese build, is well dressed, well groomed, and has good hygiene. Patient appears noticeably pregnant. 

Vital Signs: BP: 134/80, sitting                      

R: 17 breaths/min unlabored     

P:88 beats/min, regular       

T: 98.8 Degrees F (oral)                      

O2 Sat: 99% on Room air

Height: 68 inches            Weight: 316 pounds        BMI: 48

Skin- Warm and moist, smooth, good turgor, nonicteric. No lesions, masses, scars, tattoos, thicknesses or opacities.

Thorax & Lungs 

Chest – Symmetrical, no deformities, no evidence of trauma. Respirations are unlabored, no paradoxical respirations or use of accessory muscles noted. 

Heart-Regular rate and rhythm. No splitting of S2 or friction rubs appreciated. Carotid pulses are 2+ bilaterally without bruits.

Lungs – Clear to auscultation bilaterally. Chest expansion and diaphragmatic excursion symmetrical.

Abdomen- Gravid Abdomen without tenderness, no skin changes present.

Breast Exam- Breasts are pendulous in shape. There is a 6×6 cm tender fluctuant abscess present to the right inferior breast at 6oclock position, with surrounding erythema. Normal nipple and areola with drainage. Left breast normal. 

Labs/ Imaging

Labs were normal 

Assessment

Mrs. R is a 36 y/o African American pregnant female G5P2022 @ 34 weeks gestation presenting with right sided breast pain x 5 days. Also admits to erythema and swelling. Breast exam reveals a tender fluctuant abscess on right inferior breast with surrounding erythema.

Differential Diagnoses

1. Breast Abscess- has tender fluctuant mass with drainage
2. Cellulitis of the breast- has tenderness, redness, swelling and drainage, but no fever, chills, rash or streaking 
3. Mastitis- has redness, tenderness, and swelling, but no h/o breastfeeding, no fever, chills, or malaise
4. Breast Cancer- has swelling and redness, but no dimpling of breast skin, mass is fluctuant and not firm, irregular immobile
5. Fibroadenoma- mass but fluctuant, not firm, smooth, rubbery and mobile

Plan: 

1. Breast Abscess- surgery consult for incision and drainage of abscess with wound culture, administer Tylenol 975 mg PO, Clindamycin 600 mg IV piggyback, provide wound care instructions to patient
2. Pregnancy- establish prenatal care
3. Obesity- counsel about harms of obesity, importance of healthy diet and regular exercise
4. Marijuana Smoking- counsel about harms of smoking, especially while pregnant, as it passes through the blood and can harm baby’s development