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SOAP NOTE

Name: M.W

Date: 11/02/2018

Time: 10:00 AM

 

Age: 25 y/o

Sex: Female

SUBJECTIVE

CC: “I have a lump on my left breast”

HPI:  Patient is a 25-years-old White Hispanic Female The patient came to the office complaining about a mass in the left breast from 2 week ago. The lump was note while she was taking a shower. The patient denied pain in that breast, nipple discharge, or change in the in color or appearance of the skin. The patient is anxious in connection with the findings. Gynecologic history menarche: at the age of 11, with rhythm 28 x 3, denies any STDs, G0P0A0L0, sexual active, one partner.

Medications: No.

PMH: Denies

Allergies: Denies any allergies to food or medication

Medication Intolerances: Denies.

Major traumas: Denies any trauma

Hospitalizations: Denies hospitalizations

Surgeries: Denies Surgeries

Family History

Mother: Alive, Diabetes Type II.
Father: Alive,CAD
Brothers: 1 Alive and Healthy
Children: None.

Social History:

Home type: Apartment
Marital status: Single
Religion: Denies.
Tattoos: no
Alcohol: Denies
Drugs: Denies
Smoker: Non smoker
Exercise: 30- 45 minutes of walk 3 times a week
Pets: No
Travel: Denies.
Blood Transfusion: Denies

OBSTETRIC/GYNECOLOGICAL HISTORY: Single, Sexually active, Heterosexual, denies STI’s, Menarche: 11 y/o, LMP: 10/15/2018 for 3 days, regular cycle, plus the spots already described, G0T0P0A0L0, Birth Control: Yes/condom.

ROS

General

Denies any weight change in the last past 6 months denies weakness, fatigue report monthly, not fever or chills. No distress noted at this moment, responding question in an appropriated mood. No exercise intolerance.

Cardiovascular

Patient denies chest pain and palpitation. No edema noticed no syncope, no orthopnea.

Skin

Warm and dry, skin is appropriated color for ethnicity.

Respiratory

Patient denies cough, dyspnea, wheezing or hemoptysis, no acute distress at this moment.

Eyes

Denies changes in vision, no blurred vision, no diplopia, no tearing, no scotomata, and no pain.

Gastrointestinal

No nauseas, no emesis, no dysphagia, no bowel habit changes, no melena, no constipation.

Ears

Denies ear pain, hearing loss, ringing in ears, discharge, pearly grey membranes.

Genitourinary/Gynecological

Denies dysuria, frequency or urgency. Denies blood in urine. No urinary urgency, no change in nature of urine. No vaginal discharge. OBSTETRIC/GYNECOLOGICAL HISTORY: Single, Sexually active, Heterosexual, denies STI’s, Menarche: 11 y/o, LMP: 10/15/2018 for 3 days, regular cycle, plus the spots already described, G0T0P0A0L0. Sexual active, one partner.

Nose/Mouth/Throat

Denies difficulty in smelling, sinus problems, nose bleeds or discharge. Denies dysphagia, hoarseness, or throat pain.

Musculoskeletal

Denies cramps, joint stiffness, arthritis or gout, limitation of movement, history of musculoskeletal or disk diseases; denies any muscle or joint pain.

Breast

Solid mass in the left breast. Denied nipple discharge, breast pain or change in the breast skin.

Neurological

Denies history of headaches, syncope, seizures, stroke, memory disorder or mood change. No weakness, paralysis, numbness/tingling, tremors or tics, involuntary movements, or coordination problems. No mental disorders or hallucinations.

Heme/Lymph/Endo

Denies easy bruising or bleeding. No history of anemia, blood transfusions or reactions. Denies exposure to toxic agents or radiation. / Denies heat or cold intolerance, excessive sweating, polydipsia, polyphagia, or polyuria. No history of diabetes, thyroid disease, or hormone replacement.

Psychiatric

Denies depression, memory changes. Denies suicides attempts or thoughts. No history of mental illness.

OBJECTIVE

Weight:  125 lbs   

BMI: 22.1

Temp: 98.7 F

BP: 100/64 mm/Hg
Pain: 0/10

Height: 5’3’’ inch

Pulse: 74 bpm

RR: 18 bpm
O2 Saturation: 99 % at Room air

General Appearance

Patient is a 25 y/o WHF, appearing of staged age; Alert and oriented; answers questions appropriately. No acute distress at this time. AAOX4, PERRLA; answers questions appropriately. Pain level: 0/10 on scale of pain.

Skin

General appearance is normal. Normal temperature, Hydrated, no rashes or lesions described. Intact, warm, moist, good turgor. Screening for skin cancer performed no precancerous skin lesion.

HEENT

Head normocephalic, atraumatic and without lesions; hair evenly distributed. Throat: Pharynx mildly erythematous, no exudates. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa edematous, clear rhinorrhea, moderate airway obstruction. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist.

Cardiovascular

No murmur, no rubs or gallop upon auscultation.
Capillary refill 2 seconds. Regular rhythm and rate with S1, S2 normal, no S3 or S4
No edema.

Respiratory

Symmetric chest wall. Lungs: bilateral mildly, lungs clear upon auscultation, no rales, and no wheezes. Breath sounds equal, no rubs. No respiratory distress noted at this time.

Gastrointestinal

Abdomen Soft, non-tender, BS normal in all 4 quadrants. No hepatosplenomegaly, mass, or herniation

Breast

The breast tissue, nipples, and areas around the breast with normal appearance. Shape and size are normal. A small round mass (3.0 cm) is palpable in the left breast with distinct borders, firm tissue, easily moved and painless localized at 3 – 4:00. There was no nipple discharge or retraction. No axillary nodes.

Genitourinary

Genitalia:
Normally developed female genitalia. No perineal or perianal abnormalities are seen. No genital lesion or urethral discharges. No noted introitus discharge or irritation.
Speculum examination: No vaginal walls bleeding, no cervix discharge, erythema, or friability. Bimanual examination: Mobile cervix, not painful. No adnexal masses or tenderness. No pelvic pain.

Musculoskeletal

Steady gait, no limping or musculoskeletal deformities, or muscular atrophy. Thoracic and lumbar spine, normal. Full ROM in all 4 extremities, no joint stiffness.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; normal gait.
Reflexes 2+ bilaterally throughout.
CN II-XII intact.

Psychiatric

Good judgment. Alert and oriented. Dressed in clean skirt and blouse. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab /Tests/Screening/Intervention/Assessment:

1.- Bilateral whole-breast US, (ordered)
2.- Mammography (Mammogram), (ordered)
3. – CBC, BMP, U/A Reflex to culture. (ordered)

Intervention

1. Calculated BMI / in normal parameters
2. Counseling about physical activity (exercise)
3. Pain severity 0/10
4. Documentation of current medications (procedure)
5. Adult depression screening assessment

Special Tests

 Not performed.

 Diagnosis

Diagnosis:

1. Benign Neoplasm of Left Breast – (D24.2) as evidence by small round mass (2.0 cm) is palpable in the left breast with distinct borders, firm tissue, easily moved and painless, localized at 3 – 4:00 Hrs. No axillary nodes.

DIFFERENTIAL DIAGNOSTIC:

1. Malignant Neoplasms of the Breast: Breast cancer is a malignant tumor that forms from the uncontrolled growth of abnormal breast cells. Malignant tumors can invade and destroy surrounding tissue and spread to other parts of the body. Breast cancer usually affects tissues involved in milk production (ductal and lobular tissues).
2. Fibrocystic Breast Disease: The condition is very common and benign, meaning that fibrocystic breasts are not malignant (cancerous). Fibrocystic breast disease (FBD) is now referred to as fibrocystic changes or fibrocystic breast condition, is the most common cause of “lumpy breasts” and affects more than 60% of women.
3. Lipoma of the Breast: A lipoma is a benign tumor of the breast. So, fat tissue is the main component of a lipoma. Essentially, a lipoma is a pocket of fat that is encapsulated by a thin fibrous capsule. Lipomas are very common and can occur in many areas of the body.

Plan/Therapeutics & Education:

Medications: No medication is ordered.

Teaching/Education:

Dietary changes (avoid caffeine, alcohol).
You must perform a monthly breast exam at the same time each month, 1 week after your menstrual period ends.
Return to the office if you discover any new breast changes in size, shape, or contour of the breast. If a new node appears. Also, if you note a change in the appearance or feel of the skin and nipple. Return if you note spontaneous bloody or clear fluid from the nipple. Reduce or avoid caffeine and soy products.
Disease process: Fibroadenomas are a benign neoplasm of the breast that usually develop in the young women, between the age of 15 and 35 (Poter, 2011). The tumors tend to be more circumscribe and mobile and, when palpated, may feel like small, slippery marble (Llanio-Navarro & Perdomo-Gonzales, 2003). The exact causes are unknown but, development of fibroadenomas may relate to reproductive hormones. Tumors may shrink after menopause, when hormone levels decline (Poter, 2011).

Non-medication treatments: NA

Follow-ups/Referrals:

* Patient need to return to clinic in 3 weeks to evaluate the results of breast ultrasound, Mammography (Mammogram), and CBC, BMP, U/A Reflex to culture.
* Follow Dr. orders and in case of emergency please call 911 or come to nearest ER.
* Follow up in two weeks to evaluated patient and laboratory testing results.
* No referrals needed at this time.

 Evaluation of patient encounter:

Interview process went well, practitioner elaborated the plan of care with patient, and education was provided and verbalized understanding.
A palpable breast mass is the most common finding of symptomatic breast cancer. Evaluation of a breast mass begins with a detailed history, assessment of breast cancer risk, and physical examination and requires age-appropriate breast imaging. Breast masses are common and typically benign. Certain qualities of a mass (e.g. mobile, unattached to surrounding tissue, discrete, smooth surface) are reassuring to the provider that a mass in a young woman is benign. Based on the history and physical exam, the provider can often make the right diagnosis of benign or malignant but not necessarily to the degree that is reassuring for the provider and/or the patient.2 Cyst aspiration and cytology of the fluid is used in a more limited fashion and primarily only for larger, bothersome simple cysts. If aspiration is done, the fluid is non-bloody and the mass is gone, simple close follow-up is acceptable. If the mass does not totally resolve, recurs or the fluid is bloody with aspiration, a tissue biopsy is indicated. In the setting of a mass seen as solid on ultrasound, further imaging and likely biopsy may be merited. When imaging is ordered in the setting of a breast complaint, it should be diagnostic and not screening. Depending on the imaging unit, they may immediately proceed without additional orders to secondary imaging and even biopsy as indicated by the classification of the initial images. Providers should be aware of the reporting and diagnostic steps of the imaging group and ensure that subsequent reports are tracked, and follow-up is performed.

References:

Bickley, L. S. (2013). Bates’. Guide to physical examination, (11th ed.). Philadelphia, PA: wolters Kluwer Lippincott Williams & Wilkins.
Cash, J. C., & Glass, C. A. (2014). Family practice guidelines (3rd ed.). New York, NY: Springer Publishing Company.
Hawkins, J. W., Roberto-Nichols, D. M., Stanley-Haney, J. L. (2016). Guidelines for nurse practitioners in gynecologic setting (11th ed). New York, NY: Springer Publishng Company.
Llanio-Navarro, R., & Perdomo-Gonzales, G. (2003). Medical clinical propaedeutic and semiology (Vols. 1-2). Havana, Cuba: Editorial Ciencias Medicas.
Poter, R. S. (2011). The merck manual (19th ed.). West Point, P

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