Discussion:Clinic for a Wellness Visit
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Discussion:Clinic for a Wellness Visit
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
Discussion:Clinic for a Wellness Visit
Discussion:Clinic for a Wellness Visit
Discussion:Clinic for a Wellness Visit
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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