ACTUAL CASE STUDY FOR CAROLYN CROSS I
HUMAN 41 YEARS OLD FEMALE REASON FOR
ENCOUNTER : CONCERNED ABOUT HER RISK FOR
BREAST CANCER LATEST UPDATED VERSION
2025/2026 |GUARANTEED PASS A+
SOAP NOTE-iHuman case Carolyn Cross
Name: Carolyn Cross Date: Time:
Age: 41 Sex: Female
SUBJECTIVE
CC:
“I am here today for a wellness visit. I’d like to discuss a few concerns.
Especially my risk for breast cancer. Just recently both my mother, who’s
63 and my first cousin on my mother’s side were diagnosed with breast
cancer. I would like to know whether that increases my risk and if sohow
much”
https://www.coursehero.com/file/98992940/wk-7-SOAP-notedocx/
, HPI: Ms. Cross is a healthy 41-year-old who presents for a well-woman
examination. She has no major health issues but is concerned about her
risk for breast cancer. She is married with two boys age 6 and 8. The
patient reports a normal mammogram at age 40. She has a history of
fibrocystic breast disease. As a result she is concerned that she will not be
able to identify a lump.
She has no active medical complaints or health problems past or present.
She is concerned abouther risk of breast cancer because both her mother
(age 63), and maternal first cousin (age 44) have been recently diagnosed
with intraductal breast cancer. She takes no regular medications but does
take vitamin E for fibro cystic breast disease. She will periodically take
aspirin or acetaminophen for headaches. She cannot remember when her
last physical was. Her immunizations are up to date. Last gynecological
exam was 18 months ago. Patients menarche age 10.5; first pregnancy age
33; second pregnancy age 35; she breast-fed each of her two infantsfor
only four months each. The patient, reports a normal baseline
mammogram at age 40, (report not available) and a history of fibrocystic
breast disease.
Patient is of Hispanic descent. Pt has a glass of wine every night with
supper
She gardens and does house work for exercise. She enjoys cooking,
reading, and gardening. Herdiet is traditional Hispanic diet with fast food
about once a week. Both breast is irregular lump and bump bilateral with
slight diffuse tenderness. She has two boys and a husband no reported
siblings
Medications:
Vitamin E 1,000IU 1 po QD for-Fibro cystic breast disease
https://www.coursehero.com/file/98992940/wk-7-SOAP-notedocx/
, PMH: denies past medical problems. Denies chicken pox, mumps,
measles, or rheumatic fever. denies recent blood work or test completed.
Allergies: NKDA
Medication Intolerances:
Denies Chronic
Illnesses/Major traumas:
DeniesHospitalizations/
Surgeries
Patient with no past medical problems. Patient has had two normal
deliveries and a tubal ligationwhen she was 35 years-old. Few dental
procedures. Has routine dental cleanings every 6 months.
Family History
Both of her male children(age 12 & 8) have no health conditions. Father is
alive and has hyperlipidemia (no age provided) and HTN and mother just
diagnosed at 63 with breast cancer (currently receiving radiation tx).
Patient has 2 male siblings (no ages provided) and they are healthy.
Social History
Patient is a middle school learning specialist. She is married with two male
children. Wine withdinner. Denies substance use/abuse. Never smoked but
was exposed to second hand smoke growing up. Denies any safety
concerns or abuse. Always wears her seat belt. No guns in the home.
Wears helmet when riding bike or motorcycle. Has health insurance.
ROS
https://www.coursehero.com/file/98992940/wk-7-SOAP-notedocx/
HUMAN 41 YEARS OLD FEMALE REASON FOR
ENCOUNTER : CONCERNED ABOUT HER RISK FOR
BREAST CANCER LATEST UPDATED VERSION
2025/2026 |GUARANTEED PASS A+
SOAP NOTE-iHuman case Carolyn Cross
Name: Carolyn Cross Date: Time:
Age: 41 Sex: Female
SUBJECTIVE
CC:
“I am here today for a wellness visit. I’d like to discuss a few concerns.
Especially my risk for breast cancer. Just recently both my mother, who’s
63 and my first cousin on my mother’s side were diagnosed with breast
cancer. I would like to know whether that increases my risk and if sohow
much”
https://www.coursehero.com/file/98992940/wk-7-SOAP-notedocx/
, HPI: Ms. Cross is a healthy 41-year-old who presents for a well-woman
examination. She has no major health issues but is concerned about her
risk for breast cancer. She is married with two boys age 6 and 8. The
patient reports a normal mammogram at age 40. She has a history of
fibrocystic breast disease. As a result she is concerned that she will not be
able to identify a lump.
She has no active medical complaints or health problems past or present.
She is concerned abouther risk of breast cancer because both her mother
(age 63), and maternal first cousin (age 44) have been recently diagnosed
with intraductal breast cancer. She takes no regular medications but does
take vitamin E for fibro cystic breast disease. She will periodically take
aspirin or acetaminophen for headaches. She cannot remember when her
last physical was. Her immunizations are up to date. Last gynecological
exam was 18 months ago. Patients menarche age 10.5; first pregnancy age
33; second pregnancy age 35; she breast-fed each of her two infantsfor
only four months each. The patient, reports a normal baseline
mammogram at age 40, (report not available) and a history of fibrocystic
breast disease.
Patient is of Hispanic descent. Pt has a glass of wine every night with
supper
She gardens and does house work for exercise. She enjoys cooking,
reading, and gardening. Herdiet is traditional Hispanic diet with fast food
about once a week. Both breast is irregular lump and bump bilateral with
slight diffuse tenderness. She has two boys and a husband no reported
siblings
Medications:
Vitamin E 1,000IU 1 po QD for-Fibro cystic breast disease
https://www.coursehero.com/file/98992940/wk-7-SOAP-notedocx/
, PMH: denies past medical problems. Denies chicken pox, mumps,
measles, or rheumatic fever. denies recent blood work or test completed.
Allergies: NKDA
Medication Intolerances:
Denies Chronic
Illnesses/Major traumas:
DeniesHospitalizations/
Surgeries
Patient with no past medical problems. Patient has had two normal
deliveries and a tubal ligationwhen she was 35 years-old. Few dental
procedures. Has routine dental cleanings every 6 months.
Family History
Both of her male children(age 12 & 8) have no health conditions. Father is
alive and has hyperlipidemia (no age provided) and HTN and mother just
diagnosed at 63 with breast cancer (currently receiving radiation tx).
Patient has 2 male siblings (no ages provided) and they are healthy.
Social History
Patient is a middle school learning specialist. She is married with two male
children. Wine withdinner. Denies substance use/abuse. Never smoked but
was exposed to second hand smoke growing up. Denies any safety
concerns or abuse. Always wears her seat belt. No guns in the home.
Wears helmet when riding bike or motorcycle. Has health insurance.
ROS
https://www.coursehero.com/file/98992940/wk-7-SOAP-notedocx/
