Subjective
CC:
“I’m here today for a wellness visit. I’d also like to discuss a few concerns. Especially my risks for breast cancer. Just recently both my mother, who’s 63, and my first cousin on my mother’s side were diagnosed with breast cancer. I would like to know whether that increases my risk and if so how much?”.
HPI:
CC is a healthy 41-year-old G2P2 Hispanic-American female who presents for a well-woman examination. She has no active medical complaints but is concerned about her risk of breast cancer as both her mother (age 63) and maternal first cousin (age 44) have been recently diagnosed with intraductal breast cancer. Additional risk factors include menarche age 10.5; first pregnancy age 33. She breastfed each of her two infants for only four months each. The patient reports a normal baseline mammogram at age 40, (report not available) and history of fibrocystic breast disease. She is overweight (BMI 27.5) with an FH of hypertension, hyperlipidemia (father), and type 2 diabetes (mother).
Medications:
- Vitamin E 1 capsule Oral daily
- Aspirin or Acetaminophen as needed for headache
PMH: Fibrocystic Breasts
Allergies: NKDA
Medication Intolerances: Denies medication intolerance
Chronic Illnesses/Major traumas: No illnesses, no major traumas
Childhood: Had usual coughs, colds, and tummy aches.
Ob/Gyn: No illnesses. G2P2. The onset of menarche at age ten and a half. Last menstrual period two weeks ago.
Psychiatric: No illnesses including anxiety/depression
Hospitalizations/Surgeries:
- Two normal deliveries
- Tubal ligation
- A few dental procedures
Family History:
The patient has two healthy boys. Her mother who’s 63 was diagnosed with breast cancer two months ago, and her first cousin on her mother’s side who’s 44 was also diagnosed with breast cancer. They both had intraductal breast Cancer. Her father: HBP and High cholesterol. She has two sisters, and one brother who are alive and have no significant health problem
Social History:
The patient is married; she works as a middle-school learning specialist. She lives with her husband and her two boys. She does not do sports. She eats out fast food places at least once a week. She likes a traditional Hispanic diet and loves desserts. She drinks a glass of wine with dinner each night. Denies tobacco or marijuana use.
ROS
Objective
General Appearance
Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.
Skin:
Warm and dry with no lesions seen. Normal skin turgor
HEENT:
Normocephalic, atraumatic, no deformities, no visible scaliness, edema, masses, lumps, deformities, scars, rashes, nevi, or other lesions. Non-tender; Nails without ridging, pitting, or peeling, with normal capillary reflow, blanching observed. Hair with normal thickness and distribution pattern for patient gender. PERLA, EOMs intact. Eyelids: no ptosis erythema or swelling. Conjunctivae pink, no discharge, Sclerae is anicteric. No edema, redness, tenderness, or lesions noted in the orbital area. Ears with the normal-appearing of external structures, no deformities or edema, no discharge noted auditory canals patent, tympanic membrane translucent, non-injected, and pinkish-gray in color, no scaring, discharge or purulence noted, normal landmarks. Normal mobility with insufflation. No hearing deficits. Normal Weber and Rinne tests. Nose: No discharge or polyps, no edema, or tenderness over the frontal or maxillary sinuses. Nasal mucosa pink. Neck: Supple, no visible scars, deformities, or other lesions. The trachea is midline and freely mobile. Thyroid with normal limits for size and consistency. No cervical lymphadenopathy or mass, no occipital nodes. Full ROM. Oral mucosa pink and moist, good dental hygiene, normal dentition, normal odor.
Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.
Respiratory
Symmetric chest wall, the excursion with respiration is symmetrical and there are no abnormal retractions or use of accessory muscles. No distension, scars, masses, or rashes. Normal tactile fremitus. Thoracic lymph nodes are non-palpable. Respirations are regular and easy. Respirations are non-labored. Breath sounds are equal, clear to auscultation
Gastrointestinal
Abdomen middle obese, non-distended; no BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly, mass, or herniation. No tympany or shifting dullness.
Breast
Normal, symmetrical breast contour. No visible skin or nipple abnormalities, no nipple discharge or blood, no dimpling, wrinkling, or discoloration of the skin. Irregular “lumpy bumpy” consistency throughout both breasts, no suspicious, discrete palpable lesions. Slight, diffuse tenderness. No cervical, supraclavicular, infraclavicular, or axillary lymphadenopathy.
Genitourinary
The bladder is non-distended; no CVA tenderness. External genitals reveal coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions were noted. A small speculum was inserted; vaginal walls are pink and well-rated; no lesions were noted. Cervical eversion (ectropion) without friability, samples collected for PAP smear. No abnormal discharge. On the bimanual exam, the cervix is firm. Not CMT. The uterus is slightly irregular in contour; no fullness, masses, or tenderness. Adnexa difficult to palpate, nontender. Ovaries are non-palpable.
Rectal exam: no evidence of hemorrhoids, fissures, bleeding, or masses
Musculoskeletal
Normal bulk and tone, no rigidity, no asymmetry or deformity of the back, nontender to percussion, Full ROM saw in all 4 extremities as the patient moved about the exam room. Normal stability. The strength is 5/5 bilaterally.
Neurological
There is full ROM, equal bilaterally. The patient’s speech is clear. In good tone. Cranial nerves I – XII are intact. No involuntary movements. Posture erect. Balance stable; gait normal. Romberg negative, no pronator drift.
Psychiatric
Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.
Lab Tests
Mammography, screening– pending
Lipid profile, serum
Fasting blood glucose
Glycated hemoglobin (HbA1C)
Pap smear: Normal
Differential Diagnoses
1- Cervical neoplasm: Pap smear-negative, continued screening needed
It is a malignant tumor formed as a result of abnormal development of the cervical tissues. HPV is the primary risk factor for neoplasm development. However, any condition that has an immunosuppressive effect can increase the risk. This pathophysiological process begins with the abnormal development of cervical cells caused by HPV infection and if the HPV infection does cease, after passing a few developmental stages, the cells of the virus eventually turn into cancer cells. The process usually lasts for 10-15 years. At the later developmental stages, the patient may show such symptoms as vaginal bleeding after intercourse, abnormal vaginal discharge, and pain in the genital area (Borruto & Ridder, 2012).
2- Diabetes Mellitus type 2: Prediabetic state identified, family history of diabetes
In patients with type 2 diabetes, the pancreas produces insufficient amounts of insulin, or their body cannot use it adequately. As a result, the glucose level in the blood rises, and it consequently damages the blood vessels and other organs. The risk factors include genetic predisposition, as well as the combination of age and BMI. The major symptoms are severe thirst, frequent urination, rapid bodyweight loss, fatigue, irritability, and nausea (“Type 2 diabetes,” 2017).
3- Hyperlipidemia. High-moderate to high lipids identified, risk of heart disease
The condition is associated with an abnormal increase in the concentration of lipids or lipoproteins in the blood (triglycerides and cholesterol, in particular). An elevated lipid content can lead to atherosclerosis. In this case, plaques comprised of lipids are formed on the inner walls of blood vessels and arteries, thereby reducing their lumen and subsequently disrupting the blood circulation. Atherosclerosis significantly increases the chance of the progression of various pathologies in the cardiovascular system including strokes and heart attacks. The major unmodifiable risk factors for hyperlipidemia are heredity and age (older adults are more prone to the pathology). The modifiable factors include constant overeating, consumption of high-calorie food, diabetes mellitus, and hormonal disorders (Edmunds, Mayhew, & Setter, 2014).
Diagnosis
Breast Cancer Risk
CC’s major problem is the risk of breast cancer increased by the fact that two intraductal breast cancers were recently diagnosed in her family. There is also the issue of the effectiveness of mammographic tests, i.e. whether they can help identify the risk of the early development of cancer (risk due to fibrocystic breast disease). Studies definitively confirm that the relative risk for a woman to be affected by breast cancer is higher if the woman has relatives affected by it (Bevier, Sundquist, & Hemminki, 2012; Colditz, Kaphingst, Hankinson, & Rosner, 2012). Further, a connection exists between the age of menarche and the risk of breast cancer: a lesser age results in higher risk (Collaborative Group on Hormonal Factors in Breast Cancer, 2012).
The risk is remarkably higher for those women who had their first menstruation before they were 12, and the reason is exposure to estrogen, which is a contributor to the cancer risk. Concerning pregnancy, women who have their pregnancy before 30 have lower risks of breast cancer in comparison with women whose first pregnancy was after 30 (relevant for CC who was first pregnant at age 33). Finally, being overweight is a risk factor, too (Amadou et al., 2013). Therefore, CC’s risks are associated with her BMI, family history, fibrocystic breast disease, early menarche, and late first pregnancy. However, there is also one factor that can reduce the patients’ risks: she breastfed both her sons, although not for a long time, which decreases the risk of breast cancer caused by reduced exposure to estrogen.
Plan/Therapeutics
Plan:
- Further testing: yes, see below
- Medication: none
- Education: yes, see below
- Non-medication treatments: yes, see below
First of all, it is recommended to CC to undergo mammographic screening, which is initially the main purpose of her wellness visit. Expected complications include difficulties to detect malignant tumors due to the patient’s fibrocystic breast disease, but this complication is not critical under clinical conditions (cysts are transparent for scanning, unlike malignant tumors). When recommending screening, appropriate agencies take into consideration the gender, age, ethnicity, and family history of a person, and based on CC’s background, it is identified that she has relevant risks. CC might need a genetic analysis to identify whether she has genes inherited from her mother that are associated with breast cancer, as breast cancer can be hereditary. Also, it is recommended to examine the patient’s father and brothers as her first-degree relatives to specify the risks. The patient’s diet and possible sun exposure can be risks, too.
Education that CC should receive is associated with her identified level of breast cancer risks that come from her family history, pregnancy history, reproductive system development, and current health problems. Also, additional risk factors, such as being overweight and drinking alcohol, should be mentioned. Other possible diagnoses should be explained, too, to let the patient understand her risks not only in the breast cancer context but also beyond it. With risk as to the diagnosis, non-medication aspects of treatment will include providing support and ensuring the comfort of the patient as she is going through additional testing. However, in the attempt to console CC, health care providers should not try to assure her that she will never have cancer; instead, they should encourage her to accept the new round of testing and the results whatever they may be.
References
Amadou, A., Ferrari, P., Muwonge, R., Moskal, A., Biessy, C., Romieu, I., & Hainaut, P. (2013). Overweight, obesity and risk of premenopausal breast cancer according to ethnicity: A systematic review and dose-response meta-analysis. Obesity Reviews, 14(8), 665-678.
Bevier, M., Sundquist, K., & Hemminki, K. (2012). Risk of breast cancer in families of multiple affected women and men. Breast Cancer Research and Treatment, 132(2), 723-728.
Borruto, F. & Ridder, M. (2012). HPV and cervical cancer: Achievements in prevention and future prospects. New York, NY: Springer.
Colditz, G. A., Kaphingst, K. A., Hankinson, S. E., & Rosner, B. (2012). Family history and risk of breast cancer: Nurses’ health study. Breast Cancer Research and Treatment, 133(3), 1097-1104.
Collaborative Group on Hormonal Factors in Breast Cancer. (2012). Menarche, menopause, and breast cancer risk: Individual participant meta-analysis, including 118 964 women with breast cancer from 117 epidemiological studies. The Lancet Oncology, 13(11), 1141-1151.
Edmunds, M. W., Mayhew, M. S., & Setter, S. M. (2014). Pharmacology for the primary care provider. St. Louis, MO: Elsevier Mosby.
Type 2 diabetes: Overview. (2017). Web.