Shilpa Health Screen

Problem List and Summary of Medical Concerns - History of Stage II breast cancer, diagnosed 2018, treated with lumpectomy, chemotherapy, and radiation. - Complaints of fatigue and occasional bone pain. Problem 1 Fatigue, described as persistent tiredness, worse in the afternoons, and affecting daily activities. Problem 2 Occasional bone pain, specifically in the lower back, described as a dull ache. Problem 3 Anxiety related to cancer recurrence. Other Problems and Past Medical History - Hypertension, controlled with medication. - Osteoporosis, diagnosed in 2020, treated with bisphosphonates. - Family history of breast cancer (mother). Significant Symptoms - Unexplained weight loss: Patient reports a 5kg weight loss over the past 6 months. - Unexplained and regular pain (abdominal, chest, pelvic): Patient reports occasional lower back pain. Comment Patient presents with a history of breast cancer, ongoing fatigue, and bone pain. Further investigation is required to rule out recurrence or metastasis. Plan includes blood tests, bone scan, and review of current medications. Examination A - Body weight (kg): 65 kg - Body height (cm): 165 cm - BMI value and classification: 23.9 (Normal) - Blood pressure (mmHg): 130/80 mmHg - Pulse rate: 78 bpm Other Examination Findings - Palpable lymph nodes in the left axilla, approximately 1cm in diameter, mobile. Initial Test Findings - Mammogram: Shows stable findings compared to previous studies. Blood Testing Planned - Complete blood count (CBC) to assess for anaemia or other blood abnormalities. - Comprehensive metabolic panel (CMP) to assess kidney and liver function. - Bone profile to assess calcium, phosphate, and alkaline phosphatase levels. - Tumour markers (CA 15-3, CEA) to monitor for recurrence. Blood Results - Haematology: Within normal limits. - Cholesterol ratio: Within normal limits. Medical Report and Recommendations - Patient requires urgent specialist referral via two-week rule due to palpable lymph nodes and bone pain. - Two-week referral information paragraph: Patient has been informed of the potential for cancer recurrence and the need for further investigation. Referral letter sent to Dr. Emily Carter, Surgical Oncologist, for further evaluation and management. Medication - Amlodipine 5mg daily for hypertension. - Alendronate 70mg weekly for osteoporosis. Further Appointment Planned - Follow-up appointment in two weeks to discuss blood test results and specialist referral findings. Patient Agreement - Patient agreed with content, goals, and plans and consented for printing. Date of Health Screen: 1 November 2024