C350 CAROLYN CROSS I HUMAN CASE STUDY
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
How can I help you today? – wellness visit; risks for breast cancer; mother 63 and 1
st
cousin mothers side dx with breast cancer; wants to know if it increases her risk and by
how much Do you have any other symptoms or concerns we should discuss? – physical
exam, nothing more
Do you have pain anywhere? If so, where? – no, nothing unusual for me
PMHx
Can you tell me about any current or past medical problems you have had?
Any new medical issues or diagnoses since your last visit? – cousin and mother
Do you have a history of recent or current infectious disease? – no
Have you had chicken pox, mumps, measles, or rheumatic fever? – no
Do you have high blood pressure? – no
Do you have high cholesterol? – no
Have you ever had hormone replacement therapy? – no
Have you had any recent blood or lab tests? What were the results? – no
Any previous medical, surgical or dental procedures? – normal deliveries, tubal ligation, dental
procedures, regular teeth cleanings
Have you had any hospitalizations? – deliveries
Have you had any significant traumatic injuries or accidents? – no
What childhood illnesses have you had? – coughs, colds, tummy aches
Do you have any allergies, such as medications, food, and/or latex, for example? – no
Are you taking any prescription medications? – in chart
Are you taking any OTC medications? – Vitamin E and
ibuprofen When was your last physical? – a year or so ago
Are you immunizations up to date?