COMPREHENSIVE MEDICAL CASE
STUDY LAURA WOOD INDEPTH
HISTORY , EXAMINATION,
DIAGNOSIS AND TREATMENT
PLAN 2024/2025 GRADED A+.
lOMoAR cPSD|
Laura Wood: Well Woman Visit
Subjective
41- year-old female who presents today for a well-woman examination and to
discuss risks for breast cancer.
His...
Subjective
41- year-old female who presents today for a well-woman examination and to
discuss risks for breast cancer.
History of Present Illness
Carolynn Cross is a 41-year-old G2P2 female of Hispanic descent who presents to
the clinic for a wellwoman examination after her mother, age 63, and first cousin,
age 44, were both recently diagnosed with intraductal breast cancer. She currently
does not have any symptoms/complaints and is an overall healthy state. Patient has
a history of fibrocystic breast changes, reports “lumpy” breasts for long as she can
remember and performs self-breast examinations which have not revealed any new
findings. She began menses at age 10.5, her cycle is 25-26 days without any
bleeding in between, but endorses breast tenderness around menstruation, and the
last period was two weeks ago. Both her pregnancies and deliveries were normal,
with a tubal ligation after her last delivery at 35-years-old. Her previous
gynecological exam was 3 years ago and normal and she has no history of sexually
transmitted diseases. Patient’s first mammogram 18 months ago at age 40 showed
no changes, and all pap smears have been normal. She is currently concerned
about her risk for breast cancer after two of her first-degree relatives have been
diagnosed with breast cancer.
History:
Medical:
Fibrocystic breast changes
Hospitalizations/ Surgeries:
Two previous hospitalizations for delivery of her children
Bilateral tubal ligation following last delivery at age 35
Minor dental procedures and regular cleanings every 6 months
No significant trauma/injuries
GYN/OB:
G2P2; NSVD x two and breast fed both for 4 months
Started menses at age 10.5, regular cycle is 25-26 days without any bleeding in
between, and last period was 2 weeks ago
No history of sexually transmitted diseases
Fibrocystic breasts, no new lumps/discharge or skin dimpling or retractions on the
breasts
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