You are working with Dr. Stephanie Lee at her family medicine clinic.
You are working with Dr. Stephanie Lee at her family medicine clinic. Dr. Lee tells you, “The next patient, Mrs. Payne, is a 45-year-old cisgendered female who is here for a health maintenance exam.
You are working with Dr. Stephanie Lee at her family medicine clinic
You are working with Dr. Stephanie Lee at her family medicine clinic. Dr. Lee tells you, “The next patient, Mrs. Payne, is a 45-year-old cisgendered female who is here for a health maintenance exam. It looks like she hasn’t had a visit for over five years. When you’re talking with Mrs. Payne, I’d like you to find out if she has any current concerns, update her past medical history, and do a brief review of systems. Then, come on out and tell me what you’ve discovered and we’ll both go in to do the physical exam together.”
“Do you mind if I ask you a few questions to find out how you are doing?”
Mrs. Payne says, “That sounds fine.”
“What brought you in today?”
“I feel fine, but I know I should get checked out since it’s been a while and I need to have a Pap test and mammogram.”
“I would like to update your medical history. Do you have any chronic medical problems?”
“Well, I don’t really have any medical problems.”
“Have you had any operations?”
“I had my tubes tied shortly after the birth of my last child.”
“Are you on any medications, or are you allergic to any medications?”
“I take an occasional Tylenol or ibuprofen for pain or headache and a multivitamin. I’m not allergic to any medicine as far as I know.”
“Have you ever smoked?”
“Yes, I’m afraid I do smoke a pack of cigarettes a week. I keep trying to quit, but I just never seem to be able to do it.”
“Do you drink alcohol?”
“No, I don’t drink any alcohol at all.”
“Have you ever used any recreational drugs?”
“I never tried any illegal drugs. My friends have smoked marijuana but I was always too afraid to try.”
“How much do you exercise?”
“I used to try to walk at lunchtime, but I don’t do that anymore. It just seems like I’ve been too busy to have time to exercise.”
“Have you been hit, kicked, punched, or otherwise hurt by someone in the past year? If so, by whom?”
“No, I feel safe.”
“How is the health of your family members?”
“My father has high blood pressure and my mother has mild arthritis, but both are in good health. My two sisters are healthy.”
“What about your extended family?”
“I don’t know how my grandparents died, but I think one of them had diabetes. My mom’s sister has breast cancer but is doing well after surgery and chemotherapy.”
Mrs. Payne asks you, “Does having an aunt with breast cancer increase my risk of developing breast cancer? My aunt was diagnosed with breast cancer when she was about 70 years old.”
You were able to reassure Mrs. Payne that the risk is increased only if there is a history in a first-degree relative, such as a parent or sibling.
GYNECOLOGIC HISTORY HISTORY OB/GYN:
“How old were you when your periods began?”
“Around 13 or 14.”
“Are your periods usually regular?”
“They have always been regular until the last year, when my menstrual flow has decreased.”
“Can you describe what you mean?”
“My cycles have lengthened and the flow has decreased. I think I might be having hot flashes once in while, too. I’m wondering if I might be going through menopause.”
You tell Mrs. Payne you would like to address this issue in more detail when you return later with Dr. Lee.
“Have you ever had an abnormal Pap test?”
“I had one abnormal Pap test seven or eight years ago. Dr. Lee did a test and took some samples but everything turned out normal. I had another Pap test one year later that was normal. I then had another normal one a few years ago, right?”
“Right. You mentioned having a child. How many times have you been pregnant?”
“I have been pregnant three times, and I have three children.”
BREAST CANCER SCREENING TESTING
When you ask Mrs. Payne about health maintenance, she says she has never had a mammogram. She tells you, “One of the big reasons I’ve been putting off coming to see Dr. Lee is because I know she will recommend a mammogram. I think I should have one since my aunt had breast cancer and all, even though we just discussed how that shouldn’t increase my risk. But a friend of mine told me her mammogram was very painful. I have done breast self-exams, but not very often. I did notice some tenderness the last time I did my exam.”
You respond, “Let’s talk more about mammograms with Dr. Lee when she comes in. Are there any other issues you’d like to cover today?”
Mrs. Payne indicates that she’s discussed all her concerns with you already. You excuse yourself while Mrs. Payne changes into a gown for her physical exam.
After presenting Mrs. Payne’s history and vital signs to Dr. Lee, the two of you knock on the door and reenter the room. After greeting Mrs. Payne, Dr. Lee asks if she minds if you perform the physical examination with Dr. Lee observing. Mrs. Payne assents.
Physical Exam – Vital signs:
Temperature is 37 C (98.6 F)
Pulse is 81 beats/minute
Respiratory rate is 12 breaths/minute
Blood pressure is 128/72 mmHg
Weight is 81.6 kg (180 lbs)
Height is 168 cm (66 in)
BMI is 29 kg/m2
General: Mrs. Payne is a well-appearing 45-year-old female who is somewhat overweight.
Head, eyes, ears, nose, and throat (HEENT): All unremarkable. Teeth are in good repair with several fillings and some tobacco staining noted.
Neck: Normal-sized thyroid with no nodules. Trachea is in the midline.
Cardiovascular: Normal S1 and S2 with no murmurs, gallops, or rubs. Pulses are palpable and equal throughout.
Respiratory: Clear with good respiratory excursions. No palpable lymph nodes are noted in the cervical or inguinal regions.
Musculoskeletal: Good muscle development and normal range of motion of all joints.
Neurologic: Cranial nerves are intact; normal strength and sensation; reflexes are equal and also symmetrical; normal gait.
No hepatosplenomegaly, tenderness, or masses.
Dr. Lee then explains to you the correct technique for a pelvic exam, as Mrs. Payne is due for her Pap test.
Dr. Lee next inspects the cervix and vaginal walls for lesions or discharge before obtaining cytology. “Now I’m going to obtain a sample,” she tells Mrs. Payne.
Discussion Question 1
Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.
Discussion Question 2
Based on your performance and the expert feedback in your PHYSICAL EXAM collection, also, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.
Discussion Question 3
Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.
Discussion Question 4
Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.
Discussion Question 5
Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, also, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client.
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