CAROLYN CROSS I HUMAN
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HX-40% 
Physical-40% 
 
 
Problem list-20% 
HPI ( history of present illness) 
 
Yearly physical 
 
 
 
 
Chief complaint: 
 
HPI: 
 
Carolyn is an almost 40 y/o married female, G2P2 here for her yearly physical exam. She has no complaints. 
. 
 
 
 
PMH ( previous medical history) 
 
None 
 
Bilateral fibrocystic breast changes 
 
 
Allergies: Other active problems: 
 
Medical, surgical, obstetric, hospitalizations: 
Medical: None 
Surgical: G2P2; Bilateral tubal ligation following la...
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CAROLYN CROSS I HUMAN•CAROLYN CROSS I HUMAN
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CAROLYN CROSS ASSESMENT I HUMAN CASE STUDY 2024/I-Human Case Study• Por THEEXCELLENCELIBRARY
Well woman visit 
Pt 41 y/o no PMH, no new medical issues, concern about risk of breast CA. Mother age 63 diagnosed with breast CA as well as mother's side 1st cousin. Pt has naturally lumpy breasts, last year's mammogram normal. Weight gain of 5lbs. 
 
Identifies as generally healthy, no major health issues. Weight gain of 5-10lbs in last year 
No complaints of neck or ear pain, or itchy scalp. No visual or hearing issues. Occasional headaches takes Ibuprofen. 
No reports of chest pain, palpi...
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CAROLYN CROSS ASSESMENT I HUMAN CASE STUDY 2024/I-Human Case Study• Por THEEXCELLENCELIBRARY
Carolyn Cross 
 
41 y.o. F 
5’3” 
155 lb 
 
CC: well-woman evaluation 
 
Which of the following topics may be included in the well-woman evaluation of females age 40 
–	64 years? 
•	Reproductive health 
•	General medical status and current impact of past medical history 
•	Psychosocial and occupational concerns 
•	Fitness and nutrition 
•	Risk management: disease, lifestyle, habits, environment 
•	Immunization status
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CAROLYN CROSS I HUMAN•CAROLYN CROSS I HUMAN
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CAROLYN CROSS ASSESMENT I HUMAN CASE STUDY 2024/I-Human Case Study• Por THEEXCELLENCELIBRARY
Obtaining of the patient history is an important aspect in arriving at the effective interventions for the patient. Ideally, the patient history gives information on the severity of the disease, the duration which the patient has been experiencing the symptoms and the risk factors that might contribute to the malfunction (Hussain et al, 2016). 
. By asking questions to obtain information from the patient, the physician can ascertain the appropriate interventions for the patient. Failure to ask ...
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CAROLYN CROSS ASSESMENT I HUMAN CASE STUDY 2024/I-Human Case Study• Por THEEXCELLENCELIBRARY