45-Year-Old Female Wellness Visit

HISTORY

Question 1a: What are two additional questions that should have been asked in the case study?

1. Have you experienced any unusual discharge or bleeding from your vagina?

2. Are you experiencing any pain or discomfort in your breasts?

Question 2b: What is the rationale for asking these two additional questions?

The first extra question is really important because it can show if there are infections or other problems in the reproductive system. Weird discharge or bleeding might mean there’s cervical cancer or other issues in the female parts (American Cancer Society, 2022). The second question is also important because it helps check if there are any weird things happening with the breasts, like lumps, pain, or strange stuff coming out. These could be signs of breast cancer.

Question 3c: What might the two additional questions reveal about Mrs. Payne’s health?

The first extra question can help find out if the patient has signs of cervical cancer, like strange discharge or bleeding. Also, the second question can help find out if there are signs of breast cancer, like lumps, pain, or discharge. If Ms. Payne says she has discharge or bleeding from her vagina, it could mean she has an infection or something wrong with her cervix or uterus. She might need more tests or treatment. If she feels pain or discomfort in her breasts, it could be something not so serious, like fibrocystic changes, or something more serious, like breast cancer (Malherbe & Fatima, 2020).

DOMAIN: PHYSICAL EXAM

2a) Explain the reason the provider examined each system.

The physical exam is really important for checking how a patient is doing. In Ms. Payne’s case, the doctor checked her whole body to see how she’s doing, find any health problems, and decide what kind of treatment she might need. First, the doctor checked Ms. Payne’s vital signs, like her temperature, pulse, breathing rate, and blood pressure. These help see how her heart and lungs are doing. Dr. Lee also checked her weight, height, and body mass index (BMI) to see if she’s eating well and if she might have any risks for health issues related to being overweight. Then, the doctor looked at Ms. Payne’s head, eyes, ears, nose, and throat to make sure her senses are working well and to look for any problems, like stains from smoking or tooth decay, which might mean she needs to take better care of her mouth. Dr. Lee also checked Ms. Payne’s neck to see if her thyroid gland is the right size and to feel for any lumps, which might mean there’s a problem with her thyroid. Also, the doctor checked Ms. Payne’s heart and lungs to see if they’re working properly and if there are any problems, like unusual sounds, which might mean she has heart or lung issues. Finally, Dr. Lee checked Ms. Payne’s muscles and joints to see if they’re strong and if she can move them like she should. If there are any problems, it might mean she has issues with her muscles or bones (joints).

 Finally, the doctor checked Ms. Payne’s nervous system to see if her cranial nerves, which control things like smelling and seeing, are working well. They also checked how her muscles and feeling were, tested her reflexes, and watched how she walked. In short, the doctor looked at everything to really understand how Ms. Payne is doing health-wise, find any hidden health problems or things that might cause problems later on, and decide what’s the best way to help her stay as healthy as possible.

2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what exam findings could be abnormal.

As a 45-year-old woman coming in for a checkup to make sure everything’s okay, there are some things that might not seem quite right during the exam. For example, if the doctor feels any lumps or bumps in your breasts while doing a breast exam, that could be a sign that something’s not normal and needs more checking. Also, if the results of a Pap test, which checks for cervical cancer, come back not like they should be, that could be a reason for concern. And if you’re having any unusual bleeding or pain in your belly during a pelvic exam, it could be a sign of conditions like endometriosis or fibroids in your uterus.

2c. Describe the normal findings for each system.

During Ms. Payne’s checkup, the doctor looked at different parts of her body, and everything seemed normal. Her head, eyes, ears, nose, and throat were all fine, with no problems. Her teeth were in good shape, although there was some staining from tobacco. When the doctor checked her neck, her thyroid gland was normal-sized and there were no lumps, and her windpipe was in the middle where it should be. Also, her heart sounded normal, with no unusual sounds, and her pulses were strong and the same on both sides. Her breathing was clear, and she didn’t have any swollen glands in her neck or groin. Her muscles were strong and she could move all her joints normally. Lastly, her nervous system seemed to be working well, with no issues with her senses, strength, or reflexes, and she walked normally. Overall, everything seemed okay, and there didn’t seem to be any health problems to worry about.

2d) Identify the various diagnostic instruments you would need to use to examine this patient.

To check on Ms. Payne’s health, the doctor might use different tools. These include a stethoscope to listen to her heart and lungs, an ophthalmoscope to look into her eyes, and an otoscope to check her ears. They might also use a reflex hammer to test her reflexes, a tuning fork to check her hearing, a blood pressure cuff to measure her blood pressure, and a tape measure to see how tall and heavy she is. Sometimes, the doctor might also order special tests like mammograms to check her breasts and Pap tests to check her cervix. These tests help make sure everything’s okay with her breast and cervical health.

DOMAIN: ASSESSMENT (Medical Diagnosis)

N/A

DOMAIN: LABORATORY & DIAGNOSTIC TESTS

4e If this is a wellness visit, discuss what the U.S. Preventive Taskforce recommends for patients in this age group.

When a woman who’s 45 years old comes in for a checkup, it’s important to look at what the U.S. Preventive Services Task Force (USPSTF) recommends for her age group. They say that women from 50 to 74 years old should have a mammogram every two years to check for breast cancer. But for women from 40 to 49 years old, it depends on their own risks and choices whether they have a mammogram. The USPSTF also says that women from 21 to 65 years old should have a Pap test every three years to check for cervical cancer. Women who are over 65 can stop having Pap tests if they’ve had them regularly and haven’t had any abnormal results. Other important tests for women around this age include checking for colorectal cancer starting at age 50, usually with a colonoscopy every 10 years, and checking bone density starting at age 65 or earlier if needed based on their risks. It’s important to talk about these recommendations and any other tests that might be needed based on personal health and family history during the checkup.

References

American Cancer Society. (2022). Signs and Symptoms of Cervical Cancer. Cancer.org; American Cancer Society. https://www.cancer.org/cancer/cervical-cancer/detection-diagnosis-staging/signs-symptoms.html

Malherbe, K., & Fatima, S. (2020). Fibrocystic Breast Disease. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK551609/

USPSTF. (2019, January 11). Recommendation | the United States Preventive Services Taskforce. Uspreventiveservicestaskforce.org. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening

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