Kayla, 38-year-old Caucasian and Latino female
Subjective
Chief complaint: complaining of fatigue, right breast pain, and vaginal itching.
HPI: The breast pain is in the right breast and now into the right axilla. It is warm and tender to
touch. She has not noticed any nipple discharge. She has also had mild myalgia. The vaginal
itching began a few days before the breast pain. She reports a great deal of stress. She has not
been monitoring for a fever. She denies diarrhea or constipation, abdominal pain, skin changes,
cough, or chest pain. She has not had dysuria. LNMP was 6 weeks ago, 8 days in length, heavy
for 5 days with clots. Menses are irregular, having only 5 to 6 per year.
Past Medical History -Kayla denies any surgeries or past medical history other than four
pregnancies, three births, one pre-term, and two cesarean sections with the last two births. She
had one miscarriage at 10 weeks when she was 16. She also reports that she had PCOS as a
teenager and has always had irregular menses. She had gestational diabetes with the last birth.
Family History- Family History: Her paternal great grandmother died of breast cancer at the age
of 50. Mary has a history of hyperlipidemia, Type 2 DM, and Hypertension. Tom has a history of
hypertension, hyperlipidemia, and an MI with stenting 2 years ago. The mother has two siblings;
one who died in an MVA 5 years ago at the age of 18 a younger brother, and an older sister who
is 42 and lives in a large urban city in the Midwest with her family, and she is in good health but
also had PCOS and difficulty conceiving. Other family members died of old age.
Social History-15-year smoker of 1 PPD up until 18 months ago when she quit with the
pregnancy of Riley. She is concerned about finances today and reports ongoing fatigue. Not
currently sexually active, abstinent for the last 6 months. Does not exercise, drinks wine
frequently, often skips breakfast and lunch and eats whatever the children eat for dinner often
processed or quick food. She continues to live with her parents during a separation from her
husband and is working part time at the children’s school library but has not been there for over a
week. She has no health insurance, but her children are now covered by the State Medicaid
HM