History of Present Illness (HPI)
41-year-old Caucasion female presents with chief complaint of pain in chest, arm, and shoulder. Completed 6 cycles of TAC (docetaxel, doxorubicin, cyclophosphamide) with the last cycle ending 3 months ago. She is here for primary care followup and to discuss her pain symptoms.
Medications
- Tamoxifen: 20 mg by mouth daily
- Goserelin: 3.6 mg subQ every 28 days
- Lorazepam: 2 mg by mouth at bedtime as needed
- Oxycodone ER: 20 mg 1 tablet by mouth every 12 hrs
- Oxycodone/acetaminophen: 5/325 mg 1 tab Q4-6 hours PRN (take on average 2 doses daily)
- Ibuprofen: (OTC) 400 mg PRN take 2-3 doses on most days
- Senna-S: (docusate-senna) 2 tabs by mouth every morning
Past Surgical History
Bilateral skin sparing mastectomy
Axillary node dissection
Reconstruction with tissue expanders and breast implants
Family History
Father: 72 and healthy (high blood pressure); still working fulltime.
Mother: 68 and relatively healthy (high blood pressure, heartburn, depression, high cholesterol). Retired and working part-time.
No known family history of breast cancer.
Social History
Denies tobacco
Occasional alcohol intake socially
Denies recreational drug use
No current formal diet
Moderate caffeine intake
Limited exercise
Sexually active, condoms for contraception
Labs
Hemoglogin
13 (reference range: 12-16.5 (g/dL))
Hematocrit
34 (reference range: 36-50 (%))
RBC
4.2 (reference range: 4-5.5 (x 106/mL))
WBC
4 (reference range: 4-10 (x 103/mm3))
Platelet
200 (reference range:100-450 (x 103/μL))
Sodium
139 (reference range: 135-147 (mEq/L))
Potassium
4.2 (reference range: 3.5-5.2 (mEq/L))
Chloride
101 (reference range: 95-107 (mEq/L))
CO2
24 (reference range: 20-29 (mg/dL))
Urea Nitrogen
18 (reference range: 7-20 (mg/dL))
Creatinine
0.6 (reference range: 0.5-1.4 (mg/dL))
Glucose
89 (reference range: 64-128 (mg/dL))
HgbA1c
5.2 (reference range: < 5.7 (%))
Vitamin B12
312 (reference range: 200-900 (pg/mL))
Thyroid Stim Hormone
2.7 (reference range: 0.4-4 (mIU/L))
Vitals
Blood Pressure
112/74 mmHg
Heart Rate
78 (beats/min)
Respiratory Rate
20 (breaths/min)
Temperature
98°F (36.6° C)
Height
65 inches
Weight
140 lb (63 kg)
Physical Examination
GEN
Alert & oriented x 3; Affect & speech appropriate, hunched posture.
HEENT
PERRLA, conjunctiva anicteric.
ABD
Decreased bowel sounds.
PSYCH/NEURO
Fatigue, mildly anxious and depressed upon questioning.
BREAST EXAM
No lumps, breast dimpling, or puckering. No redness, scaling or inflammation. No signs of nipple discharge.
SKIN
Surgical scars healing well. EXTREMITIES: Mild swelling noted in both arms (R > L). Patient does not have full shoulder ROM bilaterally and guarding present.
Review of Systems
General
Feels fatigued and depressed
HEENT
No headaches, visual changes, sore throat
CV/Pulm
No shortness of breath or palpitations. Does describe musculoskeletal pain over anterior chest
GI/GU
Mild constipation, no urinary retention, incontinence, nausea, vomiting, or diarrhea
CNS
No dizziness, confusion, memory impairment, loss of consciousness
Ext
No swelling
Pain Symptom Assessment
The assessment uses a 10-point numeric rating scale. The first assessment covers how intensely Pam feels pain in different contexts.
Severity/Score
- Now: 5/10
- Average: 6/10
- Worst: 9/10
- Least: 5/10
The second assessment covers how the pain Pam feels interferes with different parts of her life.
Interference With/Score
- Activity: 8/10
- Mood: 6/10
- Sleep: 5/10
- Work: 3/10
- Relations: 10/10
- Enjoyment: 8/10
Characteristics
Stabbing, sharp, aching, and tender over lateral aspect of chest wall, shoulder, and occasionally the arm. It is worse in the morning and with strenuous activity. Burning, tingling, and numbness in hands and feet but improving. Aggravated by light touch, pressure, trigger point (underarm), exposure to cold air, raising arms above 90 degrees. Alleviated by meds, rest, and warm baths.
Past Medical History
- Generalized anxiety disorder
- Depression
- Breast cancer (Stage 3C invasive ductal carcinoma)
Test Your Knowledge: Morphine Equivalency
Which of the following best represents Pam’s current morphine equivalent daily dose?
