Discussion week 7

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.

  • Provide a reference for your treatment plan (in APA format). The reference may come from a journal, a book, etc.
  • Cite all sources using APA format.
  • Include three differential diagnoses and support your diagnoses with supporting literature.

diagnosis:

1- hyperlipidemia

2- type 2 diabetes mellitus

differential diagnosis:

1- breast cancer risk (based on first degree family member, early menses and late pregnancies)

1- diabetes (based on the patient is considered a prediabetic beased on labs results)

3- cardiovascular disease (based on lipid panel results)

The patient had an encounter a year before, this was the history:

Chief complaint:

Yearly physical

HPI:

Carolyn is an almost 40 y/o married female, G2P2 here for her yearly physical exam. She has no complaints.

PMH (previous medical history)

Other active problems:

None

Medical, surgical, obstetric, hospitalizations:

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

Allergies:

None

Medications:

NoneIbuprophen occasionally for headaches

Preventive Health:

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

Immunizations:

Up-to-date

FHx:

Father: hypertension, hyperlipidemiaMother: Hx of type 2 diabetesSisters: no sistersBrothers: healthy and very physically active

SHx:

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)

ROS (review of systems)

General/ Constitutional:

Normal energy levelNo sleep concernsWeight stable

Skin/Breast:

Negative except for lumpy breasts

HEENT & Neck:

Negative

Cardiovascular:

Negative

Respiratory:

Negative

Abdomen/ Gastrointestinal:

Negative

Genitourinary:

Negative

Musculoskeletal:

Negative

Allergic/Immunologic:

Negative

Lymphatic/Endocrine:

Negative

Hematologic:

Negative

Neurological:

Negative

Psychological:

Negative

Vitals

Temp:98.6 FPulse:72, rhythm: regularBP:left: 130/72Respiration:14, effort: normal

Physical Exam

Weight:

148.0 pounds

Skin/Breast:

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

HEENT & Neck:

Good dentitionThyroid within normal limits for size and consistencyNo cervical lymphadenopathy or mass

Cardiovascular:

Regular rhythm and rateNo murmur or gallopNo peripheral edema

Respiratory:

Thorax normal to percussionBreath sounds equal/clear bilaterally

Abdomen/ Gastrointestinal:

Abdomen mildly obese, nondistendedNo hepatosplenomegaly, mass, or herniationSoft, nontender throughout

Genitourinary:

Normal external genitaliaParous introitusNormal vaginal mucosaSlight cervical eversion without friability; samples collected for Pap smear completedNo abnormal discharge

Musculoskeletal:

Normal muscle tone and bulk bilaterally

Allergic/Immunologic:

Normal

Lymphatic/Endocrine:

No adenopathyThyroid normal, no nodules

Hematologic:

No ecchymosis, no petechiae

Neurological:

Reflexes 2+ bilaterally throughoutCN II-XII intact

Management Plan

Ms. Cross is a healthy 40ish woman with no acute medical issues.

1) Preventative Health

  • Mammogram ordered
  • lipid panel ordered
  • Pap smear – pending results
  • Fasting blood sugar ordered

Then for this encounter this are the labs results, the ROS and PE are the same from the previous visit.

pap smear negative

mammogram pending

 

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