,Patient Information
Name: Carolyn Cross
Age: 41 years old
Gender: Female
Height: 5’3”
Weight: 155 pounds (BMI 27.5, overweight)
Reason for Encounter: Well-woman examination, concerned
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 for a
routine well-woman examination with a primary concern about her risk
for breast cancer due to recent diagnoses of intraductal breast cancer
in her mother (age 63) and maternal first cousin (age 44). She reports
no current symptoms or complaints, stating she is in good health
overall. She performs monthly self-breast examinations (SBEs) and
, denies noticing any lumps, nipple discharge, skin changes, or breast
pain outside of mild breast tenderness during her menstrual cycle
(cyclical mastalgia), which she attributes to her history of fibrocystic
breast changes. Her last menstrual period was 2 weeks ago, and she
reports regular menses (25–26-day cycles) since menarche at age 10.5.
She had a screening mammogram at age 40 (18 months ago), which
was normal, and all prior Pap smears have been negative, with the
most recent performed 3–4 years ago. She is concerned about whether
her family history increases her breast cancer risk and seeks guidance
on screening and preventive measures.
Onset: No active symptoms; concern prompted by recent family
diagnoses.
Location: N/A (no active breast symptoms reported).
Duration: N/A (preventive visit, no acute complaints).
Characteristics: No lumps, nipple discharge, or skin changes noted
on SBE; cyclical breast tenderness related to menses.
Aggravating Factors: Breast tenderness worsens during menstrual
cycle.
Relieving Factors: Tenderness resolves post-menses; no specific
interventions reported.
Name: Carolyn Cross
Age: 41 years old
Gender: Female
Height: 5’3”
Weight: 155 pounds (BMI 27.5, overweight)
Reason for Encounter: Well-woman examination, concerned
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 for a
routine well-woman examination with a primary concern about her risk
for breast cancer due to recent diagnoses of intraductal breast cancer
in her mother (age 63) and maternal first cousin (age 44). She reports
no current symptoms or complaints, stating she is in good health
overall. She performs monthly self-breast examinations (SBEs) and
, denies noticing any lumps, nipple discharge, skin changes, or breast
pain outside of mild breast tenderness during her menstrual cycle
(cyclical mastalgia), which she attributes to her history of fibrocystic
breast changes. Her last menstrual period was 2 weeks ago, and she
reports regular menses (25–26-day cycles) since menarche at age 10.5.
She had a screening mammogram at age 40 (18 months ago), which
was normal, and all prior Pap smears have been negative, with the
most recent performed 3–4 years ago. She is concerned about whether
her family history increases her breast cancer risk and seeks guidance
on screening and preventive measures.
Onset: No active symptoms; concern prompted by recent family
diagnoses.
Location: N/A (no active breast symptoms reported).
Duration: N/A (preventive visit, no acute complaints).
Characteristics: No lumps, nipple discharge, or skin changes noted
on SBE; cyclical breast tenderness related to menses.
Aggravating Factors: Breast tenderness worsens during menstrual
cycle.
Relieving Factors: Tenderness resolves post-menses; no specific
interventions reported.
