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.
- 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
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.
Occasional alcohol intake socially
Denies recreational drug use
No current formal diet
Moderate caffeine intake
Sexually active, condoms for contraception
13 (reference range: 12-16.5 (g/dL))
34 (reference range: 36-50 (%))
4.2 (reference range: 4-5.5 (x 106/mL))
4 (reference range: 4-10 (x 103/mm3))
200 (reference range:100-450 (x 103/μL))
139 (reference range: 135-147 (mEq/L))
4.2 (reference range: 3.5-5.2 (mEq/L))
101 (reference range: 95-107 (mEq/L))
24 (reference range: 20-29 (mg/dL))
18 (reference range: 7-20 (mg/dL))
0.6 (reference range: 0.5-1.4 (mg/dL))
89 (reference range: 64-128 (mg/dL))
5.2 (reference range: < 5.7 (%))
312 (reference range: 200-900 (pg/mL))
Thyroid Stim Hormone
2.7 (reference range: 0.4-4 (mIU/L))
98°F (36.6° C)
140 lb (63 kg)
Alert & oriented x 3; Affect & speech appropriate, hunched posture.
PERRLA, conjunctiva anicteric.
Decreased bowel sounds.
Fatigue, mildly anxious and depressed upon questioning.
No lumps, breast dimpling, or puckering. No redness, scaling or inflammation. No signs of nipple discharge.
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
Feels fatigued and depressed
No headaches, visual changes, sore throat
No shortness of breath or palpitations. Does describe musculoskeletal pain over anterior chest
Mild constipation, no urinary retention, incontinence, nausea, vomiting, or diarrhea
No dizziness, confusion, memory impairment, loss of consciousness
Pain Symptom Assessment
The assessment uses a 10-point numeric rating scale. The first assessment covers how intensely Pam feels pain in different contexts.
- 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.
- Activity: 8/10
- Mood: 6/10
- Sleep: 5/10
- Work: 3/10
- Relations: 10/10
- Enjoyment: 8/10
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
- 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?