CAROLYN CROSS ASSESMENT I
HUMAN CASE STUDY 2025/2026
HX-40%
Physical-40%
Problem list-20%
HPI ( history of present
i llness)
Yearly physical
Chief
complaint:
HPI:
Carolyn is an almost 40 y/o married female, G2P2 here for her yearly physical exam. She has
no complaints.
.
PMH ( previous medical
h istory)
None
Bilateral fibrocystic breast changes
Allergies
: Other active
problems:
Medical, surgical, obstetric,
hospitalizations:
Medical: None
Surgical: G2P2; Bilateral tubal ligation following last delivery at age 35
OB/Gyn: NSVD x two; breast fed both for 4 months; premenopausal; menses regular since
age 10.5
Pap smears in the past are
negative Diet: Tries to eat a
well-balanced diet
Exercise: Walks to and from the train 5 days a week; weekend
gardening Up-to-date
Vitamin E
Ibuprophen occasionally for headaches
Family Hx
Father: Hypertension,
hyperlipidemia Mother: Hx of
type 2 diabetes Sisters: No
sisters
Brothers: Healthy and very physically active
Social Hx
Ethnicity: HispanicAmerican
Occ
upa
tion:
Mid
dlesch
ool
lear
ning
spe
ciali
st
Mari