Ihuman Carolyn Cross, a 41-year-old female, Exams of Nursing

Download Ihuman Carolyn Cross, a 41-year-old female and more Exams Nursing in PDF only on Docsity! 1 Ihuman Carolyn cross 41year-old female who presents today for a well- woman examination and to discuss risks for breast cancer. Date of Visit: July 21, 2022 Patient Name: Carolyn Cross Patient Age: 41 y/o Subjective 41- year-old female who presents today for a well-woman examination and to discuss risks for breast cancer. HOPI: Carolynn Cross is a 41-year-old G2P2 female of Hispanic descent who presents to the clinic for a well- woman examination after her mother, age 63, and first cousin, age 44, were both recently diagnosed with intraductal breast cancer. She currently does not have any symptoms/complaints and is an overall healthy state. Patient has a history of fibrocystic breast changes, reports “lumpy” breasts for long as she can remember and performs self-breast examinations which have not revealed any new findings. She began menses at age 10.5, her cycle is 25-26 days without any bleeding in between, but endorses breast tenderness around menstruation, and the last period was two weeks ago. Both her deliveries were normal, but she had a tubal ligation after her last delivery at 35-years-old. Her previous gynecological exam was 3 years ago and normal and she has no history of sexually transmitted diseases. Patient’s first mammogram 18 months ago at age 40 showed no changes, and all Pap smears have been normal. She is currently concerned about her risk for breast cancer after two of her first-degree relatives have been diagnosed with breast cancer. History: Medical: Fibrocystic breast changes Hospitalizations/ Surgeries: • Two previous hospitalizations for delivery of each of her children • Bilateral tubal ligation following last delivery at age 35 • Minor dental procedures and regular cleanings every 6 months (Surgery, year of surgery, complications/no complications) • No significant trauma/injuries GYN/OB: • G2P2; NSVD x two and breast fed both for 4 months • Started menses at age 10.5, regular cycle is 25-26 days without any bleeding in between, and last period was 2 weeks ago • No history of sexually transmitted diseases • Fibrocystic breasts, no new lumps/discharge or skin dimpling or retractions on the breasts • Last gynecological exam 3 years ago • First mammogram 18 months ago at the age of 40 was normal and Pap smears have been normal Family Hx: • Mother (living) diagnosed with intraductal breast cancer two months ago at age 63, followed by a lumpectomy and currently undergoing radiation mo • Father (living) – hypertension and hyperlipidemia • Maternal cousin (living) diagnosed with intraductal breast cancer three months ago at age 44, had a lumpectomy and currently undergoing radiation • No history of cancer in maternal or paternal grandmothers • Two brothers: healthy and very physically active Social Hx: Diet: Traditional Hispanic diet at home. Eats fast-food at least twice a week and has increased intake of desserts. Attempting to increase calcium intake and consumption of fortified foods. Exercise: Housework and gardening. Does not go to the gym or play any sports Occupation: Full-time job as a middle-school learning specialist Marital status: Married for 13 years Interpersonal violence: Lives at home with spouse and two children. Feels safe at home and with family family Religion: No religious or cultural beliefs that would prevent from receiving certain types of medical care or treatment Allergies: No known drug, food, or environmental allergies Medications: Vitamin E supplement and occasional ibuprofen for headaches Health promotion/prevention: Regular pap smears and mammograms Vaccines: Up to date on all immunizations. Flu shot this year. ROS: Constitutional: Denies fatigue, difficulty sleeping, fevers, or night swears. Endorses unintentional weight gain. Reports being generally healthy otherwise. Children: Two healthy sons, ages 8 and 6. Tobacco: No smoking or tobacco use Recreational drugs: No recreational/illicit drug use Alcohol: One glass of wine per day Sleep: An average of 6-8 hours of sleep per night Leisure activities/stress reduction: Enjoys coking, gardening, reading, and spending time with when not at work movements of the fingers and arms/hands. Negative Romberg and no pronator drift. Triceps, biceps, brachioradialis, knee/patella, ankle/achilles reflexes all +2. Dermatological: Color is appropriate for ethnicity. Skin is warm and dry with no lesions. Normal skin turgor. Nails without ridging, pitting, or peeling Endocrine: Thyroid within normal limits for size and consistency. Lymphatic: No cervical, supraclavicular, infraclavicular, or axillary lymphadenopathy or mass. Hematological: No signs of visible bruising, petechiae, or bleeding. Allergic/Immunological: No rashes, swelling, fever or signs of anaphylaxis or acute allergic reaction. Psychiatric: Normal behavior, motor activity, speech, mood, affect, thought processes, cognition, and judgment. MMSE score is 30. Laboratory data: • Glycated Hemoglobin (HbA1c): 6.4% indicates prediabetes • Serum Lipid Profile: Cholesterol = 239, HDL = 45, LDL = 159, and triglycerides = 40 indicating hyperlipidemia and suggestive of sedentary lifestyle • Pap Smear: normal, indicates minimal risk for a cervical neoplasm Imaging data: • Mammography results are pending Assessment Primary Differential Dx: Breast Cancer a. Inclusion Criteria: i. First degree family members have been diagnosed with intraductal breast cancer ii. Fibrocystic breast disease iii. Early menses and late pregnancies causing increased estrogen exposure iv. Mammogram results are pending b. Exclusion Criteria: i. Normal gynecological exam and pap smear Differentials for Primary Problem (provide 2 or more differentials, include at least one must not miss diagnoses): 2. Alternative DDX: Hyperlipidemia a. Inclusion Criteria: i. Increased cholesterol, LDL, and triglycerides suggestive of high-moderate to high risk ii. Low HDL indicates a sedentary lifestyle iii. Patient reports only doing housework or gardening and does not exercise iv. Increased fast food and sugar intake v. History of hyperlipidemia in her father b. Exclusion Criteria: I none 3. Alternative DDX: Type 2 Diabetes a. Inclusion Criteria: i. Patient reports increased intake of sugar and fast-food ii. HbA1c 6.4% predisposes patient to type 2 diabetes iii. History of Type 2 diabetes in her mother b. Exclusion Criteria: i. Currently patient is prediabetic and with diet and lifestyle medication the incidence of type 2 diabetes can be reduced Reflection- What did you learn from this case? Ihuman Carolyn cross 41year-old female who presents today for a well-woman examination and to discuss risks for breast cancer.