What would be your plan for this patient ? (diagnostic work-up, Medications, Referrals, Conservative measures, Patient education, Follow-up plan, etc) 

perative.

HEENT:  Head is normocephalic without lesions or masses. Pupils round and reactive to light accommodation. Extraocular movements intact.

Neck:  Supple.  Trachea is midline. No JVD, internal, Proper neck strength and movement.

Breast: symmetric, no lesion or discharge, palpation revels no masses or tenderness. Except for R breast lump.

Lungs:  Lung fields clear to auscultation bilaterally.  No acute respiratory distress, no accessory muscle use; No wheezing, rales or rhonchi.  Equal chest expansion bilaterally.

Cardiovascular:  Oral cavity lips moist and pink, no cyanosis.  Carotid pulses +2 palpable bilaterally, no JVD or bruit.  Upper extremities- capillary refills less than 2 seconds, no clubbing or cyanosis present.  Radial and brachial pulses +2 palpable bilaterally. Apical pulse palpable at the 5th and 6th intercostal spaces.  Apical rate and rhythm regular at 90 bpm. S1 and S2 are present without murmurs, rubs, or gallops.

Abdomen:  Flat, soft, no tender, non distended with positive bowel sounds x 4. No organs enlarged.

External Genitalia:  Redness, no lesions.

Internal Genitalia: showing redness and Gray-white color discharge with a fishy, foul rotten  odor. Vaginal walls erythematous and edematous. Cervix pink with no lesions. Specimens obtained

Bimanual: No tenderness to palpation, uterus and ovaries not enlarged.

Rectum: No masses or fissure. Stool brown test negative for occult blood.

Breast examination:  The lump the patient reports is indeed a marble-sized lump in the upper outer quadrant of the right breast.  The lump feels nodal, rather than smooth, has moderate density, and does not appear to give any discomfort to the patient when manipulated. Patient’s breast tissue is dense considering patient’s age.

Initial Post:

1-What further questions do you have for this patient at this visit? (ROS) 
(This questions will help you to narrow your differential diagnosis) 

2-What is your differential (ICD-10 Codes) diagnosis list for this visit? include at least 2 (Assessment)

3. What would be your plan for this patient ? (diagnostic work-up, Medications, Referrals, Conservative measures, Patient education, Follow-up plan, etc)