IHUMAN CASE STUDY: CAROLYN CROSS – A 41-YEAR-OLD FEMALE
WITH BREAST CANCER RISK ASSESSMENT, HYPERLIPIDEMIA, AND
PREDIABETES: WELL-WOMAN EVALUATION AND PREVENTIVE
MANAGEMENT (UPDATED 2025/2026)
PART 1: PATIENT BIO DATA & INITIAL DATA GATHERING
Category Details
Name Carolyn Cross
Age 41 years old
Gender Female
Ethnicity Hispanic descent
Occupation Middle-school learning specialist
Height 5'3" (160 cm)
Weight 148-155 lbs (67-70 kg)
BMI 27.5 (Overweight)
Source Patient (self)
Reliability Reliable, alert, and able to provide clear history
Allergies NKDA (No Known Drug Allergies)
, Chief Complaint: "I am here today for a wellness visit. I'd like to discuss a
few concerns. Especially my risk for breast cancer. Just recently both my
mother, who's 63 and my first cousin on my mother's side were diagnosed
with breast cancer. I would like to know whether that increases my risk and
if so how much"
Encounter Type: Well-woman examination / Outpatient primary care visit
Updated for 2025/2026: This case reflects current USPSTF and ACS
guidelines for breast cancer screening in women aged 40-49 with elevated
risk, as well as updated recommendations for cardiovascular and metabolic
health screening .
PART 2: PAST MEDICAL HISTORY (PMH)
Condition Details Relevance
"lumpy" breasts since Complicates self-exam;
Fibrocystic breast
adolescence, tender/swollen increases concern about
disease
before menses lump detection
Denies HTN, DM,
No other chronic
hyperlipidemia (though lab work Initially perceived as heal
conditions
later reveals issues)
Denies chicken pox, mumps,
Childhood illnesses
measles, rheumatic fever
Hospitalizations Two – both for childbirth
Key Points:
No prior breast cancer or other malignancies
No prior genetic testing for BRCA mutations
No history of chest radiation
PART 3: PAST SURGICAL HISTORY (PSH)
, Surgery Year Details
Bilateral tubal ligation Age 35 Following second delivery
Dental procedures Routine Regular cleanings every 6 months
Key Points:
No breast biopsies or breast surgeries
No hysterectomy
PART 4: MEDICATIONS
Current Medications
Medication Dose Frequency Prescriber Purpose
Fibrocystic
1,000 Self-
Vitamin E Once daily breast
IU prescribed
disease
OTC Self- Occasional
Ibuprofen PRN
dose prescribed headaches
Aspirin or OTC Self- Headaches
PRN
acetaminophen dose prescribed (periodic)
Medication Adherence
Takes Vitamin E daily as self-prescribed regimen
No prescription medications at time of presentation
OTC/Herbal Supplements
, Vitamin E only
PART 5: FAMILY HISTORY (CRITICAL)
Relative Age Condition(s) Relevance
Breast cancer
First-degree
(intraductal) –
relative with
currently receiving
Mother 63 breast cancer –
radiation after
MAJOR risk
lumpectomy; Type 2
factor
diabetes
Breast cancer Second-degree
Maternal first (intraductal) – relative with
44
cousin lumpectomy + premenopausal
radiation breast cancer
Hyperlipidemia, Cardiovascular
Father Alive
Hypertension risk
Maternal Deceased Cardiovascular
grandfather (81) disease
Maternal Prior MI, stent,
88
grandmother hypertension
[Not
Brothers (2) Healthy
specified]
Children (2) 6 and 8 Healthy males
Family History – Breast Cancer Risk Summary
WITH BREAST CANCER RISK ASSESSMENT, HYPERLIPIDEMIA, AND
PREDIABETES: WELL-WOMAN EVALUATION AND PREVENTIVE
MANAGEMENT (UPDATED 2025/2026)
PART 1: PATIENT BIO DATA & INITIAL DATA GATHERING
Category Details
Name Carolyn Cross
Age 41 years old
Gender Female
Ethnicity Hispanic descent
Occupation Middle-school learning specialist
Height 5'3" (160 cm)
Weight 148-155 lbs (67-70 kg)
BMI 27.5 (Overweight)
Source Patient (self)
Reliability Reliable, alert, and able to provide clear history
Allergies NKDA (No Known Drug Allergies)
, Chief Complaint: "I am here today for a wellness visit. I'd like to discuss a
few concerns. Especially my risk for breast cancer. Just recently both my
mother, who's 63 and my first cousin on my mother's side were diagnosed
with breast cancer. I would like to know whether that increases my risk and
if so how much"
Encounter Type: Well-woman examination / Outpatient primary care visit
Updated for 2025/2026: This case reflects current USPSTF and ACS
guidelines for breast cancer screening in women aged 40-49 with elevated
risk, as well as updated recommendations for cardiovascular and metabolic
health screening .
PART 2: PAST MEDICAL HISTORY (PMH)
Condition Details Relevance
"lumpy" breasts since Complicates self-exam;
Fibrocystic breast
adolescence, tender/swollen increases concern about
disease
before menses lump detection
Denies HTN, DM,
No other chronic
hyperlipidemia (though lab work Initially perceived as heal
conditions
later reveals issues)
Denies chicken pox, mumps,
Childhood illnesses
measles, rheumatic fever
Hospitalizations Two – both for childbirth
Key Points:
No prior breast cancer or other malignancies
No prior genetic testing for BRCA mutations
No history of chest radiation
PART 3: PAST SURGICAL HISTORY (PSH)
, Surgery Year Details
Bilateral tubal ligation Age 35 Following second delivery
Dental procedures Routine Regular cleanings every 6 months
Key Points:
No breast biopsies or breast surgeries
No hysterectomy
PART 4: MEDICATIONS
Current Medications
Medication Dose Frequency Prescriber Purpose
Fibrocystic
1,000 Self-
Vitamin E Once daily breast
IU prescribed
disease
OTC Self- Occasional
Ibuprofen PRN
dose prescribed headaches
Aspirin or OTC Self- Headaches
PRN
acetaminophen dose prescribed (periodic)
Medication Adherence
Takes Vitamin E daily as self-prescribed regimen
No prescription medications at time of presentation
OTC/Herbal Supplements
, Vitamin E only
PART 5: FAMILY HISTORY (CRITICAL)
Relative Age Condition(s) Relevance
Breast cancer
First-degree
(intraductal) –
relative with
currently receiving
Mother 63 breast cancer –
radiation after
MAJOR risk
lumpectomy; Type 2
factor
diabetes
Breast cancer Second-degree
Maternal first (intraductal) – relative with
44
cousin lumpectomy + premenopausal
radiation breast cancer
Hyperlipidemia, Cardiovascular
Father Alive
Hypertension risk
Maternal Deceased Cardiovascular
grandfather (81) disease
Maternal Prior MI, stent,
88
grandmother hypertension
[Not
Brothers (2) Healthy
specified]
Children (2) 6 and 8 Healthy males
Family History – Breast Cancer Risk Summary
