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 additional question is crucial because it can indicate the presence of infections or other abnormal conditions in the reproductive system. Unusual discharge or bleeding can indicate cervical cancer or other gynecological issues (American Cancer Society, 2022). The second question is crucial in assessing if the patient is experiencing any breast abnormalities, such as lumps, pain, or discharge, which may suggest the presence of breast cancer.
Question 3c: What might the two additional questions reveal about Mrs. Payne’s health?
The first additional question may reveal whether or not the patient is experiencing symptoms of cervical cancer, such as abnormal discharge or bleeding. In addition, the second question may reveal if the patient is experiencing symptoms of breast cancer, such as lumps, pain, or discharge. If Ms. Payne reports experiencing vaginal discharge or bleeding, this could indicate an infection or abnormal cervical or endometrial cells, which may require further testing or treatment. Breast pain or discomfort could indicate a benign condition, such as fibrocystic changes, or a more serious condition, such as breast cancer (Malherbe & Fatima, 2020).
DOMAIN: PHYSICAL EXAM
2a) Explain the reason the provider examined each system.
The physical exam is an essential aspect of patient evaluation that provides vital information about the patient’s overall health status. In Ms. Payne’s case, the provider examined each system to assess her current health status, identify any underlying medical conditions or risk factors, and determine the appropriate medical intervention. Specifically, he examined Ms. Payne’s vital signs to assess her temperature, pulse, respiratory rate, and blood pressure, which are essential to her cardiovascular and respiratory health. Dr. Lee also assessed her weight, height, and body mass index (BMI) to evaluate her nutritional status and identify any risk factors for obesity-related health issues. Additionally, the provider examined Ms. Payne’s head, eyes, ears, nose, and throat (HEENT) to assess her sensory organs and identify any abnormalities, such as tobacco staining or dental caries, which can indicate poor oral hygiene. Dr. Lee also evaluated Ms. Payne’s neck to assess her thyroid gland’s size and palpate for any nodules, which can indicate thyroid disease. Furthermore, the provider assessed Ms. Payne’s cardiovascular and respiratory systems to evaluate her heart and lung function and identify any abnormalities, such as murmurs, gallops, or rubs, which can indicate cardiovascular or respiratory disease. Moreover, he evaluated Ms. Payne’s musculoskeletal system to assess her muscle development and range of motion of all joints and identify any limitations which can indicate musculoskeletal disorders. Lastly, the provider assessed Ms. Payne’s neurologic system to evaluate her cranial nerves’ integrity, motor and sensory function, reflexes, and gait. In summary, the provider examined each system to comprehensively understand Ms. Payne’s current health status, identify any underlying medical conditions or risk factors, and determine the appropriate medical intervention to promote optimal health outcomes.
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 visiting for a wellness checkup, certain exam findings could be abnormal. For instance, any palpable masses or nodules in the breast during a breast examination could be abnormal and require further investigation. An abnormal Pap test result, which screens for cervical cancer, could also be possible. Additionally, any abnormal uterine bleeding or pelvic pain during a pelvic exam could be concerning for conditions such as endometriosis or uterine fibroids.
2c. Describe the normal findings for each system.
During the physical exam of Ms. Payne, several systems were examined and found to have normal findings. The head, eyes, ears, nose, and throat (HEENT) were unremarkable, with no abnormalities noted. In addition, her teeth were in good repair, with some tobacco staining present. Ms. Payne’s neck examination revealed a normal-sized thyroid with no nodules, and the trachea was noted to be in the midline. Moreover, the cardiovascular system exam revealed normal S1 and S2 with no murmurs, gallops, or rubs. Her pulses were palpable and equal throughout. The respiratory system was clear with good respiratory excursions, and no palpable lymph nodes were noted in the cervical or inguinal regions. Furthermore, the musculoskeletal exam revealed good muscle development with all joints’ normal range of motion. Finally, the neurologic system exam showed intact cranial nerves, normal strength and sensation, equal and symmetrical reflexes, and a normal gait. Based on this exam, all systems appeared to have normal findings, indicating no concerning medical issues.
2d) Identify the various diagnostic instruments you would need to use to examine this patient.
The various diagnostic instruments that may be used to examine Ms. Payne include a stethoscope for listening to heart and lung sounds, an ophthalmoscope for examining the eyes, an otoscope for examining the ears, a reflex hammer for testing reflexes, a tuning fork for testing hearing, a blood pressure cuff for measuring blood pressure, and a tape measure for assessing height and weight. Additionally, diagnostic imaging tests such as mammography and Pap tests may be ordered for Ms. Payne to assess 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.
As a 45-year-old female visiting for a wellness check-up, reviewing the U.S. Preventive Services Task Force (USPSTF) recommendations for this age group is essential. According to the USPSTF, women between 50 and 74 should get a mammogram every two years to screen for breast cancer (USPSTF, 2016). However, for women between the ages of 40 and 49, the decision to get a mammogram should be based on individual risk factors and preferences (USPSTF, 2016). The USPSTF also recommends that women between the ages of 21 and 65 have a Pap test every three years to screen for cervical cancer. Women over 65 can stop having Pap tests if they have had regular screenings and do not have a history of abnormal test results. Other essential screenings for women around this age include colorectal cancer screening, which should start at age 50 and be repeated every 10 years if a colonoscopy is performed, and bone density screening, which can be considered starting at age 65 or earlier based on individual risk factors. Discussing these recommendations and any additional screening tests that may be necessary based on personal health and family history during the wellness visit is essential.
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