SOAP NOTE
Identify: M.W Date: 11/02/2018 Time: 10:00 AM
Age: 25 y/o Intercourse: Feminine
SUBJECTIVE
CC: “I’ve a lump on my left breast”
HPI: Affected person is a 25-years-old White Hispanic Feminine The affected person got here to the workplace complaining a few mass within the left breast from 2 week in the past. The lump was observe whereas she was having a shower. The affected person denied ache in that breast, nipple discharge, or change within the in shade or look of the pores and skin. The affected person is anxious in reference to the findings. Gynecologic historical past menarche: on the age of 11, with rhythm 28 x three, denies any STDs, G0P0A0L0, sexual energetic, one accomplice.
Medicines: No.
PMH: Denies
Allergic reactions: Denies any allergic reactions to meals or medicine
Medicine Intolerances: Denies.
Main traumas: Denies any trauma
Hospitalizations: Denies hospitalizations
Surgical procedures: Denies Surgical procedures
Household Historical past
Mom: Alive, Diabetes Kind II.
Father: Alive,CAD
Brothers: 1 Alive and Wholesome
Kids: None.
Social Historical past:
Residence sort: Residence
Marital standing: Single
Faith: Denies.
Tattoos: no
Alcohol: Denies
Medication: Denies
Smoker: Non smoker
Train: 30- 45 minutes of stroll three instances per week
Pets: No
Journey: Denies.
Blood Transfusion: Denies
OBSTETRIC/GYNECOLOGICAL HISTORY: Single, Sexually energetic, Heterosexual, denies STI’s, Menarche: 11 y/o, LMP: 10/15/2018 for three days, common cycle, plus the spots already described, G0T0P0A0L0, Delivery Management: Sure/condom.
ROS
Common
Denies any weight change within the final previous 6 months denies weak spot, fatigue report month-to-month, not fever or chills. No misery famous at this second, responding query in an appropriated temper. No train intolerance. Cardiovascular
Affected person denies chest ache and palpitation. No edema observed no syncope, no orthopnea.
Pores and skin
Heat and dry, pores and skin is appropriated shade for ethnicity. Respiratory
Affected person denies cough, dyspnea, wheezing or hemoptysis, no acute misery at this second.
Eyes
Denies modifications in imaginative and prescient, no blurred imaginative and prescient, no diplopia, no tearing, no scotomata, and no ache. Gastrointestinal
No nauseas, no emesis, no dysphagia, no bowel behavior modifications, no melena, no constipation.
Ears
Denies ear ache, listening to loss, ringing in ears, discharge, pearly gray 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 energetic, Heterosexual, denies STI’s, Menarche: 11 y/o, LMP: 10/15/2018 for three days, common cycle, plus the spots already described, G0T0P0A0L0. Sexual energetic, one accomplice.
Nostril/Mouth/Throat
Denies issue in smelling, sinus issues, nostril bleeds or discharge. Denies dysphagia, hoarseness, or throat ache. Musculoskeletal
Denies cramps, joint stiffness, arthritis or gout, limitation of motion, historical past of musculoskeletal or disk ailments; denies any muscle or joint ache.
Breast
Strong mass within the left breast. Denied nipple discharge, breast ache or change within the breast pores and skin. Neurological
Denies historical past of complications, syncope, seizures, stroke, reminiscence dysfunction or temper change. No weak spot, paralysis, numbness/tingling, tremors or tics, involuntary actions, or coordination issues. No psychological problems or hallucinations.
Heme/Lymph/Endo
Denies straightforward bruising or bleeding. No historical past of anemia, blood transfusions or reactions. Denies publicity to poisonous brokers or radiation. / Denies warmth or chilly intolerance, extreme sweating, polydipsia, polyphagia, or polyuria. No historical past of diabetes, thyroid illness, or hormone alternative.
Psychiatric
Denies despair, reminiscence modifications. Denies suicides makes an attempt or ideas. No historical past of psychological sickness.
OBJECTIVE
Weight: 125 lbs
BMI: 22.1 Temp: 98.7 F BP: 100/64 mm/Hg
Ache: zero/10
Top: 5’three’’ inch Pulse: 74 bpm RR: 18 bpm
O2 Saturation: 99 % at Room air
Common Look
Affected person is a 25 y/o WHF, showing of staged age; Alert and oriented; solutions questions appropriately. No acute misery presently. AAOX4, PERRLA; solutions questions appropriately. Ache stage: zero/10 on scale of ache.
Pores and skin
Common look is regular. Regular temperature, Hydrated, no rashes or lesions described. Intact, heat, moist, good turgor. Screening for pores and skin most cancers carried out no precancerous pores and skin lesion.
HEENT
Head normocephalic, atraumatic and with out lesions; hair evenly distributed. Throat: Pharynx mildly erythematous, no exudates. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with constructive mild reflex; landmarks simply visualized. Nostril: Nasal mucosa edematous, clear rhinorrhea, reasonable 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. Common rhythm and fee with S1, S2 regular, 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 misery famous presently.
Gastrointestinal
Stomach Delicate, non-tender, BS regular in all four quadrants. No hepatosplenomegaly, mass, or herniation
Breast
The breast tissue, nipples, and areas across the breast with regular look. Form and dimension are regular. A small spherical mass (three.zero cm) is palpable within the left breast with distinct borders, agency tissue, simply moved and painless localized at three – four:00. There was no nipple discharge or retraction. No axillary nodes.
Genitourinary
Genitalia:
Usually developed feminine genitalia. No perineal or perianal abnormalities are seen. No genital lesion or urethral discharges. No famous introitus discharge or irritation.
Speculum examination: No vaginal partitions bleeding, no cervix discharge, erythema, or friability. Bimanual examination: Cellular cervix, not painful. No adnexal plenty or tenderness. No pelvic ache.
Musculoskeletal
Regular gait, no limping or musculoskeletal deformities, or muscular atrophy. Thoracic and lumbar backbone, regular. Full ROM in all four extremities, no joint stiffness.
Neurological
Speech clear. Good tone. Posture erect. Steadiness steady; regular gait.
Reflexes 2+ bilaterally all through.
CN II-XII intact.
Psychiatric
Logic. Alert and oriented. Wearing clear skirt and shirt. Maintains eye contact. Speech is delicate, although clear and of regular fee and cadence; solutions questions appropriately.
Lab /Checks/Screening/Intervention/Evaluation:
1.- Bilateral whole-breast US, (ordered)
2.- Mammography (Mammogram), (ordered)
three. – CBC, BMP, U/A Reflex to tradition. (ordered)
Intervention
1. Calculated BMI / in regular parameters
2. Counseling about bodily exercise (train)
three. Ache severity zero/10
four. Documentation of present drugs (process)
5. Grownup despair screening evaluation
Particular Checks
Not carried out.
Analysis
Analysis:
1. Benign Neoplasm of Left Breast – (D24.2) as proof by small spherical mass (2.zero cm) is palpable within the left breast with distinct borders, agency tissue, simply moved and painless, localized at three – four:00 Hrs. No axillary nodes.
DIFFERENTIAL DIAGNOSTIC:
1. Malignant Neoplasms of the Breast: Breast most cancers is a malignant tumor that kinds from the uncontrolled progress of irregular breast cells. Malignant tumors can invade and destroy surrounding tissue and unfold to different elements of the physique. Breast most cancers often impacts tissues concerned in milk manufacturing (ductal and lobular tissues).
2. Fibrocystic Breast Illness: The situation is quite common and benign, which means that fibrocystic breasts will not be malignant (cancerous). Fibrocystic breast illness (FBD) is now known as fibrocystic modifications or fibrocystic breast situation, is the most typical reason behind “lumpy breasts” and impacts greater than 60% of ladies.
three. Lipoma of the Breast: A lipoma is a benign tumor of the breast. So, fats tissue is the primary part of a lipoma. Primarily, a lipoma is a pocket of fats that’s encapsulated by a skinny fibrous capsule. Lipomas are quite common and may happen in lots of areas of the physique.
Plan/Therapeutics & Schooling:
Medicines: No medicine is ordered.
Educating/Schooling:
Dietary modifications (keep away from caffeine, alcohol).
You need to carry out a month-to-month breast examination on the identical time every month, 1 week after your menstrual interval ends.
Return to the workplace if you happen to uncover any new breast modifications in dimension, form, or contour of the breast. If a brand new node seems. Additionally, if you happen to observe a change within the look or really feel of the pores and skin and nipple. Return if you happen to observe spontaneous bloody or clear fluid from the nipple. Scale back or keep away from caffeine and soy merchandise.
Illness course of: Fibroadenomas are a benign neoplasm of the breast that often develop within the younger girls, between the age of 15 and 35 (Poter, 2011). The tumors are typically extra circumscribe and cellular and, when palpated, might really feel like small, slippery marble (Llanio-Navarro & Perdomo-Gonzales, 2003). The precise causes are unknown however, improvement of fibroadenomas might relate to reproductive hormones. Tumors might shrink after menopause, when hormone ranges decline (Poter, 2011).
Non-medication remedies: NA
Comply with-ups/Referrals:
* Affected person have to return to clinic in three weeks to judge the outcomes of breast ultrasound, Mammography (Mammogram), and CBC, BMP, U/A Reflex to tradition.
* Comply with Dr. orders and in case of emergency please name 911 or come to nearest ER.
* Comply with up in two weeks to evaluated affected person and laboratory testing outcomes.
* No referrals wanted presently.
Analysis of affected person encounter:
Interview course of went properly, practitioner elaborated the plan of care with affected person, and schooling was supplied and verbalized understanding.
A palpable breast mass is the most typical discovering of symptomatic breast most cancers. Analysis of a breast mass begins with an in depth historical past, evaluation of breast most cancers threat, and bodily examination and requires age-appropriate breast imaging. Breast plenty are frequent and sometimes benign. Sure qualities of a mass (e.g. cellular, unattached to surrounding tissue, discrete, easy floor) are reassuring to the supplier that a mass in a younger girl is benign. Based mostly on the historical past and bodily examination, the supplier can usually make the correct prognosis of benign or malignant however not essentially to the diploma that’s reassuring for the supplier and/or the affected person.2 Cyst aspiration and cytology of the fluid is utilized in a extra restricted trend and primarily just for bigger, bothersome easy cysts. If aspiration is finished, the fluid is non-bloody and the mass is gone, easy shut follow-up is suitable. If the mass doesn’t completely resolve, recurs or the fluid is bloody with aspiration, a tissue biopsy is indicated. Within the setting of a mass seen as stable on ultrasound, additional imaging and certain biopsy could also be merited. When imaging is ordered within the setting of a breast criticism, it needs to be diagnostic and never screening. Relying on the imaging unit, they might instantly proceed with out extra orders to secondary imaging and even biopsy as indicated by the classification of the preliminary pictures. Suppliers ought to pay attention to the reporting and diagnostic steps of the imaging group and make sure that subsequent stories are tracked, and follow-up is carried out.
References:
Bickley, L. S. (2013). Bates’. Information to bodily examination, (11th ed.). Philadelphia, PA: wolters Kluwer Lippincott Williams & Wilkins.
Money, J. C., & Glass, C. A. (2014). Household observe tips (third ed.). New York, NY: Springer Publishing Firm.
Hawkins, J. W., Roberto-Nichols, D. M., Stanley-Haney, J. L. (2016). Pointers for nurse practitioners in gynecologic setting (11th ed). New York, NY: Springer Publishng Firm.
Llanio-Navarro, R., & Perdomo-Gonzales, G. (2003). Medical scientific propaedeutic and semiology (Vols. 1-2). Havana, Cuba: Editorial Ciencias Medicas.
Poter, R. S. (2011). The merck handbook (19th ed.). West Level, P
