Notes Breast Cancer

Name:  Lisa

Date: 05/25/2019

Time: 1500

Insurance Type: (private)

Age: 60

Sex: Female

SUBJECTIVE

CC: 

“For three weeks, I have been bleeding irregularly.”

HPI: 

Mrs. Lisa, a 60-year old Caucasian GIT1R6, visits the Tn/Lyt clinic today complaining about irregular vaginal bleeds for 12 days. Lisa looks non-distressed and she claims to notice strange symptoms when bathing at her daughter’s house. At the age of 55 Lisa’s had her LMP therefore she was concerned. According to Lisa, the bleeding was “spotting” so she is now wearing one of the four panty lines per day. Mrs. Lisa states that the bleeding is sometimes brown and red in color at times. She has no idea of actions that can relieve her symptoms. Lisa rates her symptoms 1/10 as she reports no cramping or abdominal pains. The spotting is intermittent and the symptoms last few minutes or hours. Mrs. Lisa claims that the spotting develops all day and night and she has lose 80 pounds within the last two years. Lisa’s initial weight was 420 Ibs, and she now has 339 Ibs. Eliminating carbs and consuming more vegetables and lean meat in her diet is helping her lose her weight. Over the past 15 years, Lisa and her husband have not been sexually active. Mrs. Lisa’s last pap smear was in August 2017and she was negative. She claims to be diagnosed by an abnormal pap smear. Lisa has an HMO insurance plan and her last routine mammogram was in August 2017. She claims that before any procedures can be performed, diagnostic testing should be approved by insurance.

Patient’s HPI:

O- symptoms began three weeks ago

L- Vaginal bleeding.

D- The symptoms are intermittent.

C- Reports spotting in her pants.

A- The symptoms are not alleviated.

R- She does not report abdominal pains.

T- She experiences bleeding in the morning, day, and night.

T- So far, she hasn’t been treated.

S- Rates symptoms 1/10.

Naturally all women experience menopause when they reach 50 years old. This is the last stage of reproduction is a woman’s life where an amenorrhea follows 12 months after the females last menstrual cycle (Leaky, 2017). When a bleeding or spotting is detected after menopause it is considered abnormal. An encounter with a woman who experiences post-menopausal bleeding should entail treatment plan, physical examination, complete history and laboratory examination. The patient was given a complete physical exam, a comprehensive history taken, to eliminate anemia, and an endometrial biopsy a CBC was ordered to rule out endometrial cancer based on the medical recommendations.

Medications:

-Citalopram 20 mg tab twice daily- For hypertension (diagnosed 2013)-mouth

- Levothyroxine 30 mg tab once daily- For depression (diagnosed in 2011)-injection

-Lisinopril 75 mcg tab twice daily- For hypothyroidism (diagnosed in 2010)-mouth

-Glimepiride 600 mg tab once daily- For type 2 diabetes mellitus (diagnosed in 2014)-mouth

-Metformin 5 mg tab twice daily - For type 2 diabetes mellitus (diagnosed in 2005)-injection

-Omeprazole 24 mg tab thrice daily - For Gastroesophageal Reflux Disease (diagnosed in 2007)-mouth

(Morice, 2016)

PMH

Allergies: No environmental, food and medication

Medication Intolerances: Null

Chronic Illnesses (and year diagnosed)

 -Gastro-esophageal reflux disease without esophagitis

-Type 2 diabetes mellitus

-Hypothyroidism

- Primary hypertension

-Major depressive disorder

-obesity

Hospitalizations/Surgeries

 In 2011, the Lisa received a total kneel replacement. At the age of 8 she had her tonsils removed.

Family History

Mother: Deceased at age 70. Type 2 diabetes mellitus, breast cancer, uncontrollable hypertension, hypothyroidism, morbid obesity, and hyperlipidemia.

Father: Deceased at age 59. Alcoholism, type 2 diabetes mellitus, uncontrolled hypertension, esophageal cancer, hyperlipidemia.

Paternal GM: The patient’s mother had no relationship with the paternal GM. History is unknown

Paternal GF: The age is unknown, Lung cancer, and heavy smoker. Deceased. .

Sister: Age is 59. Type 2 DM, obesity, hypertension. Her age is 59

Sister: Age 58. Hyperlipidemia, type 2 DM, hypertension. Her age is 58.

Daughter: Age 43. Hypertension and obesity.

Social History

Education: General Education Degree

Occupation: She is now retired. Worked as a cook for 21 years. Lisa worked in a retail industry. Currently, she is a volunteer care giver, at Royal Care Hospital.

Living situation: The patient lives with her husband in a three-storey apartment. Their daughter lives 10 kilometers away and she visits her parents frequently.

Substance use/abuse: The patient does not use drugs.

ETOH: The patient confesses to drink a glass of wine every weekends.

Tobacco Use: When riding a motor vehicle Mrs. Lisa Always wears a seatbelt. Her home is does not include physical and emotional abuse.

ROS

General

Mrs. Lisa reports weight loss, denies fever and decrease in energy levels. 

Cardiovascular

The patient records hypertension symptoms. Denies hair loss on legs, paroxysmal nocturnal dyspnea, and chest pains .  

Skin

The patient denies abnormal lesions, changes in moles, rashes, cuts and bruises.    

Respiratory 

Lisa denies substernal chest pain, wheezing, SOB and coughs.

Eyes

Mrs. Lisa claims to wear corrective lenses to enhance vison. She then denies sudden vision changes and eye pain.  

The patient claims that she did her last eye exam in 7/2016.

Gastrointestinal

Repudiates nausea, bloating, abdominal pain, constipation, and bloody stools. 

Ears

Denies ear discharge, pain, impaction, fullness, and hearing loss.  

Genitourinary

The patient repudiate burning, urgency, color change, and frequency in urination.

Lisa denies vaginal sponging.

At age 10, the patient reports menarche.

Sexually inactive for 14 years.

Last LMP – 56 years

Last Pap: March 2017

Last Mammogram: September 2018

Nose/Throat/Mouth

Lisa denies postnasal drip, dental disorder, sinus pain and nasal discharge.

Musculoskeletal

The patient reports muscle stiffness and knee pain. Furthermore, she denies restricted range of motion.

Breast

The patient reports self-breast exams carried out monthly. She denies nipple discharge, lumps, and breasts changes.

Neurological

She denies black out spells, syncope parenthesis, and weakness

Lymph

Mrs. Lisa refutes increased thirst, easy bruising, blood transfusions and temperature intolerance.

Psychiatric

The patient admits depression and denies suicidal ideation, sleeping disorders and anxiety.

OBJECTIVE (Document in the IPPA format (except GI)

Weight 339   BMI 58.5

Temp 38.2

BP 137/83

Height 5’6”

Pulse 87

Resp 15

General Appearance

Mrs. Lisa is a 60-year old white female who appears healthy and free from distress. She is well nourished and dressed in a clean white top, brown pants and white sandals.

Skin

The patient’s skin appears intact and dry. Her skin describes Lisa as a typical Caucasian. Her skin is free from lesions, rashes, lacerations, and bruises.

HEENT

The patient’s head is atraumatic, free from lesions, and normocephalic. Her hair is evenly distributed. Eyes: EOMs. PEERL intact. No scleral or conjunctival injection.

Ears: The patient’s external canals are patent. Landmarks easily visualized.

Nose: Normal turbinate. Pink nasal mucosa.

Neck: Supple. Full ROM. free from nodules. Moist oral mucosa.

Pharynx: The patient does not have erythematous.

Presence of dental decay in the lower incisor.

Cardiovascular

The heart has S1 and S2 and its RRR. Free from murmurs and rubs.

Respiratory

The respiration patterns are regular. No coughs. The chest wall is symmetrical. The patient speech has no hoarseness. The lungs sound have no crackles, rhonchi, or stridor.

Gastrointestinal

No hepatosplenomegaly and masses. The abdomen is obese and the bowel sounds are present. The patients denies rebound tenderness.

Breast

The patient’s nipple are equally round and symmetrical. The breasts from selling and palpable axillary lymph.

Genitourinary

The patient’s external genitalia reveals minimal public hair. In her body pigments, the skin color is consistent. On the vaginal opening and labia minora, small amount of blood is observed. The vaginal examination reveals no unusual odor, scant opaque discharge and gross lesions. Bimanual examinations reveals no masses or adnexa pain. The ovaries re non-palpable and the uterus anteverted. The rectal examination reveals no external hemorrhoids and bladder distention.

Musculoskeletal

In the waiting area, the full ROM is noted.

Neurological

The patient gait and speech is normal.

Psychiatric

The patients speech is clear, her thoughts coherent and maintains eye contact in every conversation.

Lab Tests (9/18/2018)

TSH-1.9

CBC-Pending

A1c-9.0

CMP-pending

Special Tests:

Pap smear and endometrial biopsy (Pending)

 Diagnosis

· 1- Polyp of cervix uteri (T342) - Cervical polyps are asymptomatic and they are discovered during gynecological exam. They are therefore considered as differential diagnosis. Cervical polyps look like spongy lesions whose stalks prolapses through the canal (Hawkins, 2016). Spotting after sexual intercourse, vaginal douching and exercising are symptoms of cervical polyps. In the examination the patient revealed no cervical lesions. She also denies sexual intercourse and cervical douching.

· 2-Leiomyoma of uterus (D25) - Leiomyoma is also known as uterus fibroids. They are characterized as growths in the external uterine surface. Typical fibroids are commune during woman’s fertile years and regress during menopause (MacNab, 2016). In this scenario, Lisa is 60 years old. Its symptoms include change in urine control, irregular menses, pelvic pain and dysmenorrhea (Hawkins, 2016). Mrs. Lisa denied urine problems. The practitioner can palpate a fibroid when examining the abdomen depending on its size and location. During the pelvic examination, palpable masses were reported. The confirmation of fibroid is confirmed by transvaginal ultrasound.

· 3- Malignant neoplasm (C741) - The symptoms of malignant neoplasm is post-menopausal bleeding. Its risk factors include poly ovarian cystic disease, obesity, and diabetes. An endometrium dilation will confirm the presence of cancer. Mrs. Lisa is diabetic but endometrium cancer cannot be diagnosed due to insurance approval.

Diagnosis

· Postmenopausal bleeding (N 156) - Postmenopausal bleeding is a fatal condition which involves abnormalities such as hyperplasia, polyps and adenomyosis. The preceptor argues that Lisa has developed endometrial cancer. This is because obese women tend to have a high risk of cancer. The final diagnosis is postmenopausal bleeding.

Plan

· Plan: 

· Testing: Pap smear test and endometrial biopsy is waiting for approval.

· Lisa is enlightened that endometrial biopsy is a step in managing her care. The student and physician discuss on the possibility of receiving an aggressive approach of determining the cause of vaginal bleeding. The approaches are curettage and dilation (Bailey, 2019). The practitioners informed Lisa that she is very suspicious of endometrium cancer. She was educated on the difference between cervical, ovarian and endometrium cancer. The patient was also enlightened on treatment plans that can be performed which include:

Lymph node dissection

Non medication: none

Follow up: Lisa will be contacted when she is approved to conduct endometrial biopsy by the insurance.

 Evaluation of patient encounter