Medical History For Fibrocystic Breast Disease Discussion Paper

Posted: December 2nd, 2022

Medical History For Fibrocystic Breast Disease Discussion Paper

Subjective

Carolyn Cross is a 41-year-old female with a past medical history significant for fibrocystic breast disease who presents today for a well-exam.

HOPI: Ms. Cross, a 41-year-old woman in good health, comes in for a routine well-woman check. She does not have any serious health problems, but she is anxious about her chance of developing breast cancer. She is married and has two sons, ages 6 and 8 years. At the age of 40, the patient states that her mammography was normal. She has a family history of fibrocystic breast disease, which is a kind of cancer. As a consequence, she is frightened that she will be unable to distinguish between a lump and anything else. She does not have any active medical complaints or health difficulties, either in the past or in the present. In recent years, both her mother (age 63) and maternal first cousin (age 44) have been diagnosed with intraductal breast cancer, prompting her to be anxious about her own chance of developing the disease.  The only medicine she takes is vitamin E for fibro cystic breast disease. To relieve headaches, she will sometimes take aspirin or acetaminophen. She has no recollection of when she last had a physical. Her vaccinations are current. Gynecological examination was last performed 18 months ago. Her menarche occurred at the age of 10.5; her first pregnancy occurred at the age of 33; her second pregnancy occurred at the age of 35; she nursed each of her two babies for exactly 4 months each. The patient has a history of fibrocystic breast disease and had normal baseline mammography at the age of 40. Medical History For Fibrocystic Breast Disease Discussion Paper

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History:

Medical: fibrocystic breast disease

Surgical: Tubal ligation at age 35

GYN/OB: 1^st Menarche (period): 10.5 years; 1^st pregnancy: 33 years normal delivery, 2^nd pregnancy: 35 years normal delivery. Normal baseline mammography at the age of 40.

Family Hx: Father – Hypertension, Hyperlipidemia; Mother – Type 2 Diabetes , diagnosed with intra-ductal breast cancer 2 months ago; 2 Brothers healthy, physically active; 1^st cousin maternal side- diagnosed with intra-ductal breast cancer 5 months ago.

Social Hx:

Diet: Traditional Hispanic diet; Fast food and pizza at least once per week, cookies during the evening, uses 1% milk

Exercise: Housework and gardens and for exercise

Occupation: Full time job as middle school learning specialist

Marital status: Married for 14 years.

Interpersonal violence: Lives in safe suburban area with no violence

Children: 2 sons (6 and 8 years old)

Tobacco: never used tobacco

Recreational drugs: denies illicit drug use

Alcohol: Has 1 glass of wine per day with dinner

 

Allergies: None

 

Medications: Vitamin E 1,000IU 1 po QD for-Fibro cystic breast disease

Health promotion: wears her seat belt. No guns in the home

Vaccines: Immunizations up to date. Received Flu Vaccine this year

ROS:

Constitutional: Reports weight increase, denies fever, pain, or fatigue.

HEENT: Denies using corrective lenses and visual changes. Denies ear pain, hearing loss, ringing in ears, or drainage. Denies sinus issues, dysphagia, nose bleeds or discharge, dental problems or sore throat.

Respiratory: Denies cough, wheezing, hemoptysis, dyspnea

Cardiovascular: Denies chest pain, palpitations, or edema.

Gastrointestinal: Denies abdominal pain, nausea, vomiting, constipation, ulcers, or eating disorders.

Genitourinary: Denies urgency, frequency, burning, or change in color of urine.

Musculoskeletal: Denies back pain, muscle or joint swelling, stiffness or pain

Neurological: Denies syncope, paresthesias, seizures, weakness, and paralysis.

Dermatological: Denies rash, itching, or moles.

Endocrine: Denies heat or cold intolerance, increased thirst or hunger

Lymphatic: Denies swollen glands. No history of splenectomy.

Hematological: Denies bleeding, bruising, or blood transfusion

Allergic/Immunological: Denies history of asthma, hives, eczema or rhinitis.

Psychiatric: Denies depression, anxiety, sleep problems, or suicidal ideation

 Objective

 Vitals:

Ht 5’3”

Wt 155b llb

BMI 27.5

BP 134/74

HR 76

RR RR

T 98.4

 

PE:

General survey: Healthy appearing adult female in no acute distress. Alert and oriented.

HEENT: Scalp normal, non-tender. Normocephalic, no deformities. Symmetric facial features. Frontal and Maxillary Sinuses non-tender. Eyes normal sclera- anicteric. 20/20 vision. PEERLA. Ears normal and clear. Hearing normal. No nasal polyps. Good dental hygiene, normal dentition.

Respiratory: Symmetric chest wall. Unlabored and regular respirations; lungs clear to auscultation bilaterally.

Cardiovascular: S1, S2 with regular rate and rhythm. No gallops, clicks, rubs or murmurs. Capillary refill less than 3 seconds. Pulses 3+ throughout. No edema.

Gastrointestinal: Non-distended abdomen, mildly obese. Normal bowel sounds in all quadrants. Normal auscultation of abdominal and femoral arteries. No hepatosplenomegaly, masses or hernias. Soft non-tender throughout. Normal percussion no fluid shift.

Genitourinary: Normal external genitalia. Parous introitus, normal vaginal mucosa. Cervical eversion without friability, samples collected for pap smear. No abnormal discharge. Uterus firm slightly irregular contour per bimanual exam. Adnexa difficult to palpate, non-tender Medical History For Fibrocystic Breast Disease Discussion Paper

Musculoskeletal: Full ROM in all 4 extremities. Strength 5/5 bilaterally

Peripheral vascular: normal vascularity. Normal ankle brachial pressure index.

Neurological: Clear speech clear. Erect posture. Stable balance; steady gait. Cranial nerves I-XII intact.

Dermatological: Warm, Dry Skin, no lesions. Normal Skin Turgor.

Lymphatic: No lymphadenopathy noted. Cervical, Supraclavicular, Infraclavicular, Axillary lymph nodes normal.

Psychiatric: Alert and oriented. Well-groomed. Maintains eye contact. Speech is soft, though clear and of normal rate and rhythm.

Laboratory data: Cholesterol: 239 (H) (>239); HDL: 45 (moderate risk); LDL: 159 (Moderate risk 130-159); Triglycerides: 40 (35-135); Glucose: 122 (8 hours fasting); Hemoglobin A1C: 6.4% (elevated risk 5.7-6.4); Pap smear- normal.

 Assessment

 Primary Differential

1- Breast Cancer Risk:

Patient has an elevated risk of breast cancer owing to a first-degree relative having the disease, as well as higher estrogen exposure to the breast tissue during early menses and late pregnancies.

The results of the mammogram are awaited..

 Differentials for Primary Problem

1. Diabetes:

Ms. Cross was identified as a prediabetic after undergoing a screening test. This would be the ideal moment to lower her chance of developing diabetes by increasing her physical activity, losing weight, and highlighting the benefits of eating carbs in moderation.

1. Cardiovascular Disease:

Ms. Cross’s lipid levels were found to be in the high-moderate-to-high range, indicating that she is at increased risk of cardiovascular disease. This might be a good opportunity to talk about diet interventions.

 Reflection- Carolyn Cross’s case was both intriguing and difficult to deal with. I thought I did an excellent job on the subjective component, and I was astonished to find out that I only missed one important question. I like to set myself a personal aim of asking all of the important questions. It is quite helpful that there is a “hints” option to assist me in determining where I should target my questioning Medical History For Fibrocystic Breast Disease Discussion Paper

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Carolyn Cross 

41-year-old Hispanic Female Height: 5’3” weight: 155 pounds BMI: 27.5 Overweight

Temp: 98.4 Oral    Pulse: 76 Regular   RR: 16 regular unlabored     BP: 134/74 elevated      SPO2: 98 % RA Skin Warm/Dry     Allergies: NONE

Pt’s Chief Complaint: “I’m just here for a wellness check-up. I just want to know my risks of having breast cancer since my mother and my cousin were recently diagnosed.”

History of Present Illness: Pt presents 41 y/o H.F. with G2P2 for well woman examination. Denies Medical Hx. Breast CA concerns: risk as her mother & Maternal 1^st cousin were just recently diagnosed with intra-ductal Breast CA S/P lumpectomies and current Radiation. Patient is afraid. C/O fibrocystic changes w/ “cysts that come & go” dx by previous MD. R/T hormones from menstrual cycle. Breasts have “Lumpy/Bumpiness”. 0 pain/discomfort (slight tenderness. 1^st mammogram at 40 years of age (18 months ago – normal, no report available). Previous Pap smear 3 years ago. Performs regular self-breast exams (per patient no lumps, bumps, or discharge). O new findings.

Past Medical History: Healthy G2P2 Hispanic Woman with no active medical complaints. 1^st Menarche (period): 10.5 years; 1^st pregnancy: 33 years normal delivery, 2^nd pregnancy: 35 years normal delivery; Tubal ligation at 35 years of age. Breastfed both children until 4 months of age. Fibrocystic Breast Disease which patient takes vitamin E capsules. Only hospitalizations with pregnancies and tubal.

Preventative Health:  Performs Self Breast Exams (per patient no lumps, bumps, or discharge noted); Breast tenderness with menstruation; Immunizations up to date. Received Flu Vaccine this year; 1^st Mammogram 18 months ago (Baseline) – normal, no report available. Receives regular dental care and cleanings every 6 months.

Social History: Gardens and Housework for exercise; used to walk to train but now drives; Traditional Hispanic diet; Fast food and pizza at least once per week, cookies during the evening, uses 1% milk; Lives with Husband of 14 years and has 2 sons (6 and 8 years old); Lives in safe suburban area with no violence; good neighborhood with good access to healthcare, food, shopping, services, and jobs; Has 1 glass of wine per day with dinner, never smoked, and denies any illicit drug use. Full time job as middle school learning specialist. No issues with ADL’s and has good health literacy.

Family History: Father – Hypertension and Hyperlipidemia; Mother – Type 2 Diabetic and diagnosed with intra-ductal breast cancer 2 months ago at age 63 (s/p lumpectomy and currently undergoing radiation); 2 Brothers both physically active and healthy; 1^st cousin maternal side diagnosed with intra-ductal breast cancer 5 months ago at age 44 (chemo and radiation).

Labs: Cholesterol: 239 (H) (>239); HDL: 45 (moderate risk); LDL: 159 (Moderate risk 130-

159); Triglycerides: 40 (35-135); Glucose: 122 (8 hours fasting); Hemoglobin A1C: 6.4% (elevated risk 5.7-6.4); Pap smear- normal

Current Medications: Vitamin E QD for fibrocystic breast disease, ibuprofen for rare Headaches Medical History For Fibrocystic Breast Disease Discussion Paper

EXAM:

General: Gained few pounds since last visit, denies cough, night sweats.

Skin/Hair/Nails: Warm, Dry Skin, no lesions. Normal Skin Turgor. No ridging, pitting, or peeling of the nails. Cap Refill < 3seconds to both finger and toes. Quincke’s test Blanching Observed

HEENT: Scalp normal, non-tender. Normocephalic, no deformities. Symmetric facial features.

Frontal and Maxillary Sinuses non-tender. Eyes normal sclera- anicteric. 20/20 vision. PEERLA. Ears normal and clear. Hearing normal. No nasal polyps. Good dental hygiene, normal dentition.

Neck: Trachea normal midline and freely moveable. Thyroid normal. Swallow normal. No cervical masses or lymphadenopathy. ROM in neck normal. JVP normal. Carotid pulses normal.

Breasts: Normal symmetric contours. No visible skin or nipple abnormalities. No spontaneous or expressed nipple blood or discharge. Irregular “lumpy Bumpy” consistency throughout both breasts. No discrete, suspicious, or palpable lesions. Slight diffuse tenderness to exam reported.

Lymphatic: No lymphadenopathy noted. Cervical, Supraclavicular, Infraclavicular, Axillary lymph nodes normal.

Chest Wall and Lungs: Symmetrical chest, Anterior-posterior (AP) diameter is normal. Excursion with respirations is symmetrical and there are no abnormal retractions or use of accessory muscles. No tenderness, lumps, or masses. Normal Tactile Fremitus. Normal Percussion. Auscultation – Normal Both Lungs.

Heart: PMI 5^th intercostal space at the midclavicular line. Normal JVP. Heart sounds normal.

Abdomen: Non-distended, mildly obese. Normal bowel sounds in all quadrants. Normal auscultation of abdominal and femoral arteries. No hepatosplenomegaly, masses or hernias. Soft non-tender throughout. Normal percussion no fluid shift.

Extremities: no cyanosis, clubbing, or deformities. No swelling or tenderness, muscle rigidity or resistance none noted. Medical History For Fibrocystic Breast Disease Discussion Paper

Musculoskeletal: Normal bulk and tone, no rigidity. No asymmetry or deformities of the back. No localized tenderness in the spine or pelvic structures. Non-tender percussion. Good stability and ROM. 5/5 strength bilaterally.

Vascular: normal vascularity. Normal ankle brachial pressure index (normal 1-1.4).

Neurological: mini-mental state exam – 30/30. Cranial Nerve intact. Balance normal. Gait and stance normal posture and gait. Muscle Bulk and tone (normal). No involuntary movements. Point to point (Fingers to nose) normal, Point to Point (Heel down shin) normal. Rapidly alternating movements fingers – normal. Negative Romberg – no pronator drift. ROM – equal bilaterally, normal.

Genitourinary: Normal external genitalia. Parous introitus, normal vaginal mucosa. Cervical eversion (Ectropion) without friability, samples collected for pap smear. No abnormal discharge. Uterus firm slightly irregular contour per bimanual exam. Adnexa difficult to palpate, non-tender.

Rectal: No visible fissures, induration, or lesions. Normal sphincter tone. No masses or tenderness. Stool brown, guaiac negative.

i-Human Comprehensive

SOAP Note

 

Date of Visit:

Patient Name:

Patient Age:

 

Subjective

___ is a ___-year-old ____ with a past medical history significant for _____ who presents today for ________________________.

HOPI: (Using OLDCARTS to guide as much as able. You may not be able to obtain all of the OLDCARTS elements a well visit but obtain as much information as you can. The HOPI should be written in paragraph format. (Focus on the reason for the visit for a well-exam- in this case, obtaining a thorough breast, GYN, OB, and menstrual history) Medical History For Fibrocystic Breast Disease Discussion Paper

 

History:

(COMPLETE medical, surgical, family, social history, allergies, current mediations. etc.)

 

Medical: (dx, year the dx was made, controlled/uncontrolled)

 

Surgical: (Surgery, year of surgery, complications/no complications)

 

GYN/OB: (para/gravida, menarche, cycle details, STI hx, breast health, last GYN exam, last pap test, last mammogram)

 

Family Hx: (include 3 generations: parents, siblings, and children of the patient), document the relationship to patient, their dx, age at diagnosis, living/deceased status for EACH family member. Also include information on any other relatives with familial diseases such as cancer and genetic disorders).

 

Social Hx: (include all of the following and be as specific as possible)

Diet:

Exercise:

Occupation:

Marital status:

Interpersonal violence:

Children:

Tobacco:

Recreational drugs:

Alcohol:

Sleep:

Leisure activities/stress reduction:

Religion:

 

Allergies: (allergen, reaction, rate severity) Medical History For Fibrocystic Breast Disease Discussion Paper

 

Medications: (medication name, dose, indication)

 

Health promotion: (think general safety: sunscreen, seatbelt use, etc..)

 

Vaccines: (be as specific as possible: for any specific vaccine information that is known, be sure to list the vaccine by name and the date it was received)

 

ROS:

(Review of Systems – Include ALL body systems: Remember these are symptoms you are asking the patient about; this IS NOT not your physical exam!).

 

Constitutional:

 

HEENT:

 

Respiratory:

 

Cardiovascular:

 

Gastrointestinal:

 

Genitourinary:

 

Musculoskeletal:

 

Peripheral vascular:

 

Neurological:

 

Dermatological:

 

Endocrine:

 

Lymphatic:

 

Hematological:

 

Allergic/Immunological:

 

Psychiatric:

 

Objective

 

Vitals:

Ht

Wt

BMI

BP

HR

RR

T

 

PE:

(Physical Exam – Include ALL body systems):

 

General survey:

 

HEENT:

 

Respiratory:

 

Cardiovascular:

 

Gastrointestinal:

 

Genitourinary:

 

Musculoskeletal:

 

Peripheral vascular:

 

Neurological:

 

Dermatological:

 

Endocrine:

 

Lymphatic:

 

Hematological:

 

Allergic/Immunological:

 

Psychiatric:

 

 

Laboratory data: (Not graded- but good for experience)

Test: Result: Implications

 

Imaging data: (Not graded- but good for experience)

Test: Result: Implications

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Assessment

 

Primary Differential (what you think the patient has. If you do not have enough information to make a diagnosis, you can list the problem with as most specificity as possible. Ex: mixed urge and overflow incontinence, etc.) Medical History For Fibrocystic Breast Disease Discussion Paper.

Dx:

1. 1. Inclusion Criteria:

 

1. 1. Exclusion Criteria:

 

 

Differentials for Primary Problem (provide 2 or more differentials, include at least one must not miss diagnoses):

1. Alternative DDX:
   1. Inclusion Criteria:

 

1. 1. Exclusion Criteria:

 

1. Alternative DDX:
   1. Inclusion Criteria:

 

1. 1. Exclusion Criteria:

 

1. Alternative DDX:
   1. Inclusion Criteria:

 

1. 1. Exclusion Criteria:

 

(You can also include additional problems here if you have identified them. Patients may come with more than one complaint and you may choose to diagnose or create a differential for multiple issues.)

Reflection- What did you learn from this case?  Medical History For Fibrocystic Breast Disease Discussion Paper

i-Human Comprehensive SOAP Note Date of Visit: Patient Name: Patient Age: Subjective ___ is a ___-year-old ____ with a past medical history significant for _____ who presents today for ________________________. HOPI: (Using OLDCARTS to guide as much as able. You may not be able to obtain all of the OLDCARTS elements a well visit but obtain as much information as you can. The HOPI should be written in paragraph format. (Focus on the reason for the visit for a well-exam- in this case, obtaining a thorough breast, GYN, OB, and menstrual history) History: (COMPLETE medical, surgical, family, social history, allergies, current mediations. etc.) Medical: (dx, year the dx was made, controlled/uncontrolled) Surgical: (Surgery, year of surgery, complications/no complications) GYN/OB: (para/gravida, menarche, cycle details, STI hx, breast health, last GYN exam, last pap test, last mammogram) Family Hx: (include 3 generations: parents, siblings, and children of the patient), document the relationship to patient, their dx, age at diagnosis, living/deceased status for EACH family member. Also include information on any other relatives with familial diseases such as cancer and genetic disorders). Social Hx: (include all of the following and be as specific as possible) Diet: Exercise: Occupation: Marital status: Interpersonal violence: Children: Tobacco: Recreational drugs: Alcohol: Sleep: Leisure activities/stress reduction: Religion: Allergies: (allergen, reaction, rate severity) Medications: (medication name, dose, indication) Health promotion: (think general safety: sunscreen, seatbelt use, etc..) Vaccines: (be as specific as possible: for any specific vaccine information that is known, be sure to list the vaccine by name and the date it was received) ROS: (Review of Systems – Include ALL body systems: Remember these are symptoms you are asking the patient about; this IS NOT not your physical exam!). Constitutional: HEENT: Respiratory: Cardiovascular: Gastrointestinal: Genitourinary: Musculoskeletal: Peripheral vascular: Neurological: Dermatological: Endocrine: Lymphatic: Hematological: Allergic/Immunological: Psychiatric: Objective Vitals: Ht Wt BMI BP HR RR T PE: (Physical Exam – Include ALL body systems): General survey: HEENT: Respiratory: Cardiovascular: Gastrointestinal: Genitourinary: Musculoskeletal: Peripheral vascular: Neurological: Dermatological: Endocrine: Lymphatic: Hematological: Allergic/Immunological: Psychiatric: Laboratory data: (Not graded- but good for experience) Test: Result: Implications Imaging data: (Not graded- but good for experience) Test: Result: Implications Assessment Primary Differential (what you think the patient has. If you do not have enough information to make a diagnosis, you can list the problem with as most specificity as possible. Ex: mixed urge and overflow incontinence, etc.). Dx: a. Inclusion Criteria: b. Exclusion Criteria: Differentials for Primary Problem (provide 2 or more differentials, include at least one must not miss diagnoses): 2. Alternative DDX: a. Inclusion Criteria: b. Exclusion Criteria: 3. Alternative DDX: a. Inclusion Criteria: b. Exclusion Criteria: 4. Alternative DDX: a. Inclusion Criteria: b. Exclusion Criteria: (You can also include additional problems here if you have identified them. Patients may come with more than one complaint and you may choose to diagnose or create a differential for multiple issues.) Reflection- What did you learn from this case?