Carolyn Cross 41 years old female came to the clinic for a wellness visit, She also like to discuss a few concerns, especially her risk for breast cancer. She stated that recently both her mother who’s 63 and her first cousin on her mother’s side were diagnosed with breast cancer, then now she wants to know whether that increases her risk and if so how much.<\/p>\n
diagnosis:<\/p>\n
1- hyperlipidemia<\/p>\n
2- type 2 diabetes mellitus<\/p>\n
differential diagnosis:<\/p>\n
1- breast cancer risk (based on first degree family member, early menses and late pregnancies)<\/p>\n
1- diabetes (based on the patient is considered a prediabetic beased on labs results)<\/p>\n
3- cardiovascular disease (based on lipid panel results)<\/p>\n
The patient had an encounter a year before, this was the history:<\/p>\n
Chief complaint:<\/p>\n
Yearly physical<\/p>\n
HPI:<\/p>\n
Carolyn is an almost 40 y\/o married female, G2P2 here for her yearly physical exam. She has no complaints.<\/p>\n
PMH (previous medical history)<\/p>\n
Other active problems:<\/p>\n
None<\/p>\n
Medical, surgical, obstetric, hospitalizations:<\/p>\n
Medical: noneSurgical: G2P2; Bilateral tubal ligation following last delivery at age 35OB\/Gyn: NSVD x two; breast fed both for 3 months; premenopausal; menses regular since age 10.5<\/p>\n
Allergies:<\/p>\n
None<\/p>\n
Medications:<\/p>\n
NoneIbuprophen occasionally for headaches<\/p>\n
Preventive Health:<\/p>\n
Pap smears in the past are negative; last one 3-4 years agoDiet: tries to eat a well-balanced dietExercise: Walks to and from the train 5 days a week; weekend gardening<\/p>\n
Immunizations:<\/p>\n
Up-to-date<\/p>\n
FHx:<\/p>\n
Father: hypertension, hyperlipidemiaMother: Hx of type 2 diabetesSisters: no sistersBrothers: healthy and very physically active<\/p>\n
SHx:<\/p>\n
Ethnicity: Hispanic-AmericanOccupation: Middle-school learning specialistMarital status: married x ~13 yearsChildren: 2 sons (5ish and 7ish)Tobacco: neverRecreational drugs: neverAlcohol: wine (one glass at dinner most days)<\/p>\n
ROS (review of systems)<\/p>\n
General\/ Constitutional:<\/p>\n
Normal energy levelNo sleep concernsWeight stable<\/p>\n
Skin\/Breast:<\/p>\n
Negative except for lumpy breasts<\/p>\n
HEENT & Neck:<\/p>\n
Negative<\/p>\n
Cardiovascular:<\/p>\n
Negative<\/p>\n
Respiratory:<\/p>\n
Negative<\/p>\n
Abdomen\/ Gastrointestinal:<\/p>\n
Negative<\/p>\n
Genitourinary:<\/p>\n
Negative<\/p>\n
Musculoskeletal:<\/p>\n
Negative<\/p>\n
Allergic\/Immunologic:<\/p>\n
Negative<\/p>\n
Lymphatic\/Endocrine:<\/p>\n
Negative<\/p>\n
Hematologic:<\/p>\n
Negative<\/p>\n
Neurological:<\/p>\n
Negative<\/p>\n
Psychological:<\/p>\n
Negative<\/p>\n
Vitals<\/p>\n
Temp:98.6 FPulse:72, rhythm: regularBP:left: 130\/72Respiration:14, effort: normal<\/p>\n
Physical Exam<\/p>\n
Weight:<\/p>\n
148.0 pounds<\/p>\n
Skin\/Breast:<\/p>\n
No pallor, jaundice, ecchymoses, or rashNormal, symmetrical breast contourNo visible skin or nipple abnormalitiesNo spontaneous or expressed nipple discharge or bloodIrregular “lumpy bumpy” consistency through both breasts; no suspicious, discrete palpable lesionsSlight tenderness to exam reported<\/p>\n
HEENT & Neck:<\/p>\n
Good dentitionThyroid within normal limits for size and consistencyNo cervical lymphadenopathy or mass<\/p>\n
Cardiovascular:<\/p>\n
Regular rhythm and rateNo murmur or gallopNo peripheral edema<\/p>\n
Respiratory:<\/p>\n
Thorax normal to percussionBreath sounds equal\/clear bilaterally<\/p>\n
Abdomen\/ Gastrointestinal:<\/p>\n
Abdomen mildly obese, nondistendedNo hepatosplenomegaly, mass, or herniationSoft, nontender throughout<\/p>\n
Genitourinary:<\/p>\n
Normal external genitaliaParous introitusNormal vaginal mucosaSlight cervical eversion without friability; samples collected for Pap smear completedNo abnormal discharge<\/p>\n
Musculoskeletal:<\/p>\n
Normal muscle tone and bulk bilaterally<\/p>\n
Allergic\/Immunologic:<\/p>\n
Normal<\/p>\n
Lymphatic\/Endocrine:<\/p>\n
No adenopathyThyroid normal, no nodules<\/p>\n
Hematologic:<\/p>\n
No ecchymosis, no petechiae<\/p>\n
Neurological:<\/p>\n
Reflexes 2+ bilaterally throughoutCN II-XII intact<\/p>\n
Management Plan<\/p>\n
Ms. Cross is a healthy 40ish woman with no acute medical issues.<\/p>\n
1) Preventative Health<\/p>\n
Then for this encounter this are the labs results, the ROS and PE are the same from the previous visit.<\/p>\n
pap smear negative<\/p>\n
mammogram pending<\/p>\n","protected":false},"excerpt":{"rendered":"
Carolyn Cross 41 years old female came to the clinic for a wellness visit, She also like to discuss a few concerns, especially her risk for breast cancer. She stated that recently both her mother who’s 63 and her first Read More …<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[],"tags":[],"class_list":["post-54332","post","type-post","status-publish","format-standard","hentry"],"_links":{"self":[{"href":"https:\/\/www.benedictsol.com\/blogs\/wp-json\/wp\/v2\/posts\/54332","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.benedictsol.com\/blogs\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.benedictsol.com\/blogs\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.benedictsol.com\/blogs\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.benedictsol.com\/blogs\/wp-json\/wp\/v2\/comments?post=54332"}],"version-history":[{"count":0,"href":"https:\/\/www.benedictsol.com\/blogs\/wp-json\/wp\/v2\/posts\/54332\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.benedictsol.com\/blogs\/wp-json\/wp\/v2\/media?parent=54332"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.benedictsol.com\/blogs\/wp-json\/wp\/v2\/categories?post=54332"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.benedictsol.com\/blogs\/wp-json\/wp\/v2\/tags?post=54332"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}