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I HUMAN CAROLYN CROSS CASE STUDY 41 YEAR OLD FEMALE BREAST CANCER CASE PLAN
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I HUMAN CAROLYN CROSS CASE STUDY 41 YEAR OLD FEMALE BREAST CANCER CASE PLAN
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By: S77566 • 3 weeks ago
By: S77566 • 3 weeks ago
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I HUMAN CAROLYN CROSS CASE STUDY 41 YEAR OLD FEMALEBREAST CANCER CASE PLAN
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 well-
woman 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
Last gynecological exam 3 years ago
, First mammogram 18 months ago at the age of 40 was normal and Pap smears have been normal
Family Hx:
Mother (living) diagnosed with intraductal breast cancer two months ago at age 63, followed by a
lumpectomy and currently undergoing radiation, and type 2 diabetes
Father (living) – hypertension and hyperlipidemia
Maternal cousin (living) diagnosed with intraductal breast cancer three months ago at age 44, had a
lumpectomy and currently undergoing radiation
No history of cancer in maternal or paternal grandmothers
Two brothers: healthy and very physically active Social Hx:
Diet: Traditional Hispanic diet at home. Eats fast-food at least twice a week and has increased intake of
desserts. Attempting to increase calcium intake and consumption of fortified foods.
Exercise: Housework and gardening. Does not go to the gym or play any sports
Occupation: Full-time job as a middle-school learning specialist
Marital status: Married for 14 years
Interpersonal violence: Lives at home with spouse and two children. Feels safe at home and with family
Children: Two healthy sons, ages 8 and 6.
Tobacco: No smoking or tobacco use
Recreational drugs: No recreational/illicit drug use
Alcohol: One glass of wine per day
Sleep: An average of 6-8 hours of sleep per night
Leisure activities/stress reduction: Enjoys cooking, gardening, reading, and spending time with family
when not at work
Religion: No religious or cultural beliefs that would prevent from receiving certain types of medical care
or treatment
Allergies: No known drug, food, or environmental allergies
Medications: Vitamin E supplement and occasional ibuprofen for headaches
Health promotion/prevention: Regular pap smears and mammograms, performs selfbreast exams, tries
to prepare meals at home
Vaccines: Up to date on all immunizations accept yearly pneumonia vaccine. Flu shot this year.
Review of Systems:
Constitutional: Denies fatigue, difÏculty sleeping, fevers, or night swears. Endorses unintentional weight
gain. Reports being generally healthy otherwise.
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