Carolyn Cross – I-Human
Patient and Encounter
● Patient: Carolyn Cross
● Age: 41-year-old female
● Obstetric history: G2P2
● Reason for encounter: Well-woman examination and breast-cancer risk evaluation
● Setting: Outpatient primary-care/well-woman clinic
● PMH: Fibrocystic breast changes; otherwise healthy
● Current complaint: No acute complaint; concerned about increased breast-cancer risk
● Family history: Mother diagnosed with breast cancer at age 63; maternal first cousin diagnosed
at age 44
● Previous mammogram: Normal; approximately 18 months ago
● Breast history: Long-standing "lumpy" breasts with cyclic tenderness; no new lump or nipple
discharge reported
● Medications: Vitamin E; occasional ibuprofen for headaches
● BMI: Approximately 27.5
History
General
● How can I help you today?
● What concerns do you have about your health?
● What specific concerns do you have about breast cancer?
● When did you first become concerned about your breast-cancer risk?
● Have you noticed any recent changes in your breasts?
Breast-Specific
● Have you noticed any new breast lumps?
● Have you noticed any nipple discharge?
● Have you noticed skin dimpling or retraction?
● Have you noticed changes in the size or shape of either breast?
● Do your breasts become tender at certain times of your menstrual cycle?
● Do you perform breast self-examinations?
● Have you ever had an abnormal mammogram?
● When was your last mammogram and what were the results?
● Have you ever had a breast biopsy?
● Have you ever been diagnosed with fibrocystic breast disease?
Family History
Patient and Encounter
● Patient: Carolyn Cross
● Age: 41-year-old female
● Obstetric history: G2P2
● Reason for encounter: Well-woman examination and breast-cancer risk evaluation
● Setting: Outpatient primary-care/well-woman clinic
● PMH: Fibrocystic breast changes; otherwise healthy
● Current complaint: No acute complaint; concerned about increased breast-cancer risk
● Family history: Mother diagnosed with breast cancer at age 63; maternal first cousin diagnosed
at age 44
● Previous mammogram: Normal; approximately 18 months ago
● Breast history: Long-standing "lumpy" breasts with cyclic tenderness; no new lump or nipple
discharge reported
● Medications: Vitamin E; occasional ibuprofen for headaches
● BMI: Approximately 27.5
History
General
● How can I help you today?
● What concerns do you have about your health?
● What specific concerns do you have about breast cancer?
● When did you first become concerned about your breast-cancer risk?
● Have you noticed any recent changes in your breasts?
Breast-Specific
● Have you noticed any new breast lumps?
● Have you noticed any nipple discharge?
● Have you noticed skin dimpling or retraction?
● Have you noticed changes in the size or shape of either breast?
● Do your breasts become tender at certain times of your menstrual cycle?
● Do you perform breast self-examinations?
● Have you ever had an abnormal mammogram?
● When was your last mammogram and what were the results?
● Have you ever had a breast biopsy?
● Have you ever been diagnosed with fibrocystic breast disease?
Family History
