Week 6 and 7: Discussion SOAP Notes Case A
Name: X.X. Date: XX Age: 40
Gender: Female Marital Status: Married Occupation: Waitress
Examiner: APRN-BC Time: 9:15 am
HPI: Patient reports that after reading a recent article in Women’s Health magazine, she decided to do a self-breast exam. This was the first time she had performed such an exam and is unsure of the results. Patient reports that during the self-exam she felt a “marble-sized” mass in the upper, outer quadrant of her right breast. Patient reports that the mass was moveable and was not painful or tender to the touch. Patient states that the self-breast exam occurred about ten days ago. She is unaware of any changes in the mass. Also she reports some itching and burning sensation in vaginal area. Patient stated she is having regular monthly menstruation.
BP 128/82; T 98.1 F; P 64; R 25. Patient is verbally responsive, demonstrates fluid coordination in large and small movements, and reports no pain or discomfort. Patient is a non-smoker and an occasional drinker. Patient states that she drinks approximately 3 alcoholic drinks per week with friends. Patient is slightly overweight with a BMI of 29.8.
PMH: Patient has no chronic illnesses. Patient suffered from pneumonia for approximately four weeks in November 2007.
Family History: Patient is one of three children. Her siblings are both males. Mother died in a car crash at the age of 69 and had no chronic conditions apart from mild arthritis. Father is still alive and is undergoing treatment for lung cancer.
Sexual Health: Married, but she believes her husband goes around and maybe have another sexual partner. She uses birth control pills to prevent pregnancy, but husband uses no condoms. She is afraid to confront husband regarding this issue. She is willing to talk to a therapist if it is need it.
Medications: use of contraceptives Altavera.
ROS: Patient has itching and burning sensation (vaginal area) showing some discomfort symptoms. Also patient present symptom is a marble-sized lump in right breast.
Allergies: NKA, immunizations current.
General: In no acute distress. Alert and oriented x 3. Appropriate and cooperative.
HEENT: Head is normocephalic without lesions or masses. Pupils round and reactive to light accommodation. Extraocular movements intact.
Neck: Supple. Trachea is midline. No JVD, internal, Proper neck strength and movement.
Breast: symmetric, no lesion or discharge, palpation revels no masses or tenderness. Except for R breast lump.
Lungs: Lung fields clear to auscultation bilaterally. No acute respiratory distress, no accessory muscle use; No wheezing, rales or rhonchi. Equal chest expansion bilaterally.
Cardiovascular: Oral cavity lips moist and pink, no cyanosis. Carotid pulses +2 palpable bilaterally, no JVD or bruit. Upper extremities- capillary refills less than 2 seconds, no clubbing or cyanosis present. Radial and brachial pulses +2 palpable bilaterally. Apical pulse palpable at the 5th and 6th intercostal spaces. Apical rate and rhythm regular at 90 bpm. S1 and S2 are present without murmurs, rubs, or gallops.
Abdomen: Flat, soft, no tender, non distended with positive bowel sounds x 4. No organs enlarged.
External Genitalia: Redness, no lesions.
Internal Genitalia: showing redness and Gray-white color discharge with a fishy, foul rotten odor. Vaginal walls erythematous and edematous. Cervix pink with no lesions. Specimens obtained
Bimanual: No tenderness to palpation, uterus and ovaries not enlarged.
Rectum: No masses or fissure. Stool brown test negative for occult blood.
Breast examination: The lump the patient reports is indeed a marble-sized lump in the upper outer quadrant of the right breast. The lump feels nodal, rather than smooth, has moderate density, and does not appear to give any discomfort to the patient when manipulated. Patient’s breast tissue is dense considering patient’s age.
1-What further questions do you have for this patient during this visit? (ROS) (These questions will help you to narrow your differential diagnosis)
2-What is your differential (ICD-10 Codes) diagnosis list for this visit? include at least 2 (Assessment) and your primary ICD10
3. What would be your plan for this patient ? (diagnostic work-up, Medications, Referrals, Conservative measures, Patient education, Follow-up plan, etc)
Note: Please use proper references and rationals for your differential Diagnosis ( ICD10) and your plan of care.