CAROLYN CROSS IHUMAN CASE STUDY (41- YEAR-OLD FEMALE CONCERNED ABOUT HER RISK FOR BREAST)LATEST REVIEW NEWEST VERSION FROM EXPERTFEEDBACK

CAROLYN CROSS IHUMAN CASE STUDY (41- YEAR-OLD FEMALE CONCERNED ABOUT HER RISK FOR BREAST) LATEST REVIEW NEWEST VERSION FROM EXPERT FEEDBACK
SOAPNOTE-iHuman case Carolyn Cross
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
forbreast cancer. Just recently both my mother, who’s 63 and my first cousin on my mother’s
sidewere diagnosed with breast cancer. I would like to know whether that increases my risk
and if sohow much”
HPI: Ms. Cross is a healthy 41-year-old who presents for a well-woman examination. She
hasno 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 offibrocystic 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.
Herimmunizations are up to date. Last gynecological exam was 18 months ago. Patients
menarcheage 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

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