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NUR 522 I human Carolyn cross 41year-old female who presents today for a well-woman
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NUR 522 I human Carolyn cross 41year-old female who presents today for a well-woman
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I human 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 no t 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 a go 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 lump ectomy and currently undergoing radiation mo NURS 522 • 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 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 family when not at work 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.The benefits of buying summaries with Stuvia:
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