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Carolyn Cross 41 y.o. F 5’3” 155 lb CC: well-woman evaluation Which of the following topics may be included in the well-woman evaluation of females age 40 – 64 years? • Reproductive health • General medical status and current impact of past medical history • Psychosocial and occupational concerns • Fitness and nutrition • Risk management: disease, lifestyle, habits, environment • Immunization status How can I help you today? – wellness visit; risks for breast cancer; mother 63 and 1st cousin mothers side dx with breast cancer; wants to know if it increases her risk and by how much Do you have any other symptoms or concerns we should discuss? – physical exam, nothing more Do you have pain anywhere? If so, where? – no, nothing unusual for me PMHx Can you tell me about any current or past medical problems you have had? Any new medical issues or diagnoses since your last visit? – cousin and mother Do you have a history of recent or current infectious disease? – no Have you had chicken pox, mumps, measles, or rheumatic fever? – no Do you have high blood pressure? – no Do you have high cholesterol? – no Have you ever had hormone replacement therapy? – no Have you had any recent blood or lab tests? What were the results? – no Any previous medical, surgical or dental procedures? – normal deliveries, tubal ligation, dental procedures, regular teeth cleanings Have you had any hospitalizations? – deliveries Have you had any significant traumatic injuries or accidents? – no What childhood illnesses have you had? – coughs, colds, tummy aches Do you have any allergies, such as medications, food, and/or latex, for example? – no Are you taking any prescription medications? – in chart Are you taking any OTC medications? – Vitamin E and ibuprofen When was your last physical? – a year or so ago Are you immunizations up to date? Yes Have you had a flu shot? Yes Have you had a pneumovax injection? – no Have you had your TDAP? – why do I need to know Have you recently traveled? Where did you go? – no At what age did your periods begin? – age 10.5 How regular are your periods? – regular like every 25-26 days with no bleeding between When did your last period begin? – 2 weeks ago Do you have breast fullness or tenderness a few days before the start of your period? – yes What other symptoms do you have with your period? (Abdominal pain, headache, bloating, etc.) – none How many live births have you had? – 2 children, 2 pregnancies Were there any complications when you gave birth to your child? – no When and what were the result of your GYN exam? – around 3 yrs ago Have you ever had a pap smear? – yes, always normal Do you perform breast self examination? – yes Tell me about the health of your grandparents, parents, and children. – mom 63 diagnosed with breast ca, 1st cousin 44 mother side breast ca – both had lumpectomy and receiving radiation; father has HTN and Hyperlipidemia; no sisters; brothers are healthy Are there any diseases that run in your family? – now yes Do you know of any genetic diseases that are found in your family? – no Social Hx Where were you born and where did you grow up? – here What is your ancestry? – Hispanic descent Where and with whom are you living? – husband and boys Do your religious or cultural beliefs … ? – no What is your educational background? – why do I need to know What is your highest level/grade in school? – why am I asking What is your native language? How well do you understand English? – understands Within your list of responsibilities … - whey do I need to know Tell me about your work. – middle-school learning specialist Do you drink alcohol? If so, what do you drink and how many drinks per day? – glass of wine