,Patient Information
Name: Carolyn Cross
Age: 41 years old
Gender: Female
Height: 5’3”
Weight: 155 pounds (BMI 27.5 kg/m², overweight)
Reason for Encounter: Well-woman examination, concern about
breast cancer risk
Setting: Primary care clinic
Class: 6512, Week #4
History of Present Illness (HPI)
Carolyn Cross, a 41-year-old Hispanic-American female, presents to the
primary care clinic for a routine well-woman examination, expressing
concern about her risk for breast cancer due to recent diagnoses of
intraductal breast cancer in her mother (diagnosed at age 63) and
maternal first cousin (diagnosed at age 44). She reports no current
breast symptoms, such as lumps, nipple discharge, skin changes, or
, non-cyclical pain, and states she feels healthy overall. She performs
monthly self-breast examinations (SBEs) and notes only cyclical breast
tenderness (rated 3/10) associated with her menstrual cycle, which she
attributes to her history of fibrocystic breast changes (benign, lumpy
breast tissue). Her last menstrual period was 2 weeks ago, with regular
25–26-day cycles since menarche at age 10.5. She had a screening
mammogram at age 40 (18 months ago), which was normal (BI-RADS 1,
negative), and all prior Pap smears have been negative, with the most
recent performed 3–4 years ago. Carolyn is worried about her family
history and seeks guidance on whether she needs earlier or more
frequent screening, genetic testing, or preventive measures to reduce
her breast cancer risk.
Onset: No active symptoms; concern prompted by family history
of breast cancer.
Location: N/A (no active breast symptoms reported).
Duration: N/A (preventive visit, no acute complaints).
Characteristics: Cyclical breast tenderness (mild, premenstrual);
no lumps, nipple discharge, skin changes, or non-cyclical pain
noted on SBE.
Aggravating Factors: Breast tenderness worsens premenstrually.
Name: Carolyn Cross
Age: 41 years old
Gender: Female
Height: 5’3”
Weight: 155 pounds (BMI 27.5 kg/m², overweight)
Reason for Encounter: Well-woman examination, concern about
breast cancer risk
Setting: Primary care clinic
Class: 6512, Week #4
History of Present Illness (HPI)
Carolyn Cross, a 41-year-old Hispanic-American female, presents to the
primary care clinic for a routine well-woman examination, expressing
concern about her risk for breast cancer due to recent diagnoses of
intraductal breast cancer in her mother (diagnosed at age 63) and
maternal first cousin (diagnosed at age 44). She reports no current
breast symptoms, such as lumps, nipple discharge, skin changes, or
, non-cyclical pain, and states she feels healthy overall. She performs
monthly self-breast examinations (SBEs) and notes only cyclical breast
tenderness (rated 3/10) associated with her menstrual cycle, which she
attributes to her history of fibrocystic breast changes (benign, lumpy
breast tissue). Her last menstrual period was 2 weeks ago, with regular
25–26-day cycles since menarche at age 10.5. She had a screening
mammogram at age 40 (18 months ago), which was normal (BI-RADS 1,
negative), and all prior Pap smears have been negative, with the most
recent performed 3–4 years ago. Carolyn is worried about her family
history and seeks guidance on whether she needs earlier or more
frequent screening, genetic testing, or preventive measures to reduce
her breast cancer risk.
Onset: No active symptoms; concern prompted by family history
of breast cancer.
Location: N/A (no active breast symptoms reported).
Duration: N/A (preventive visit, no acute complaints).
Characteristics: Cyclical breast tenderness (mild, premenstrual);
no lumps, nipple discharge, skin changes, or non-cyclical pain
noted on SBE.
Aggravating Factors: Breast tenderness worsens premenstrually.
