Breast exam soap note

Breast Cancer SOAP note

Name Sharon Broom

Date: January/17/2020.

Age: 45 years old

Gender: Female

Time:12:45

SUBJECTIVE:

Chief Complaint: “I have a sore lump on the left breast."

History of Present Illness:

Sharon is a 45-year-old female with complaints of a painful lump on her left breast for a month. The patient indicates that she feels unbalanced lumps on her left breast that are painful on the outer and upper corners. The patient observed the areas of the left outer breast worsening in terms of size and pain in the past week. She has experienced the pain of level four out of ten. Her mother was detected to have breast cancer prior to the age of 50. She has had a history of hysterectomy because of irregular periods, menorrhagia. The patient refutes swelling, increased warmth, and redness of the left breast. She repudiates nipple discharge swollen glands, chills, and fever.

History

Past Medical History:

Fibrocystic breast disease, Vitamin D deficiency, Urinary tract infection, Hypothyroidism, Hypocalcemia, and Constipation

Screenings:

Blood Pressure screening (2016 N/A)

Dental Examination (2016 N/A)

Eye Examination (2016 N/A)

Mammogram (2016 BiRad 2)

Pap smear- normal

HPV test- normal

GTPAL: G=1.T=0. P=0. A=0. L=1 (Normal vaginal delivery without complication)

Menstrual Hx: started at the age of 14. Normal PAP outcomes. LMP (cannot recall)-hysterectomy (07.2012)

Post Hospitalizations: Admitted to hospital for hysterectomy for one week

Past Surgical History: Hysterectomy (07. 2012)

Medications:

Armour Thyroid 30mg oral tablet: consume two pills on Monday, Wednesday, and Friday and three pills other days.

Therapy: 15 May 2015

Last Rx: 5 April 2016

Allergies:

Food allergies, Penicillin Triple Sulfa Vaginal CREA

Family History:

The patient’s mother passed away at the age of fifty, with a medical history of breast cancer. Sharon’s father is still alive at the age of seventy, with a medical record of hypertension. The patient has a younger brother aged 35 years and has no medical glitches. The patient has a sixteen-year-old son, who is healthy.

Social History:

The patient is divorced, and she lives with her son. She does not smoke but consumes alcohol irregularly. Sharon takes a regular diet that has no restrictions. She has no worries about weight loss or gains since she exercises two to three times weekly. The patient continually puts on a seatbelt when driving, wears sunscreen.

Sexual/Contraceptive History:

She has not been sexually active for at least a year, but previously, she had a monogamous relation. Birth control: Utilized condoms before. The patient has no fears with sexual performance or feelings.

Travel History:

She has not travelled out of the U.S.

Immunizations:

All her childhood and adulthood vaccinations are up to date

Review of Systems (Subjective):

General. The patient refutes fever, fatigue, or chills.

Skin, hair, nails: Repudiates excessive sweating, change in texture, or pigmentation. Refutes changes in nails, hair, and skin

HEENT: Refutes vertigo or headaches. No complaints of vision loss, tearing, redness, or eye discharge. No criticisms of hearing loss, swallowing difficulty, and ear drainage. Denies rhinorrhea or nasal congestion — no bleeding gums.

Neck: Refutes swollen glands, pain, or lumps. Repudiates discomfort of the neck

Respiratory: Repudiates shortness of breath, wheezing, or cough.

Cardiovascular: No latest EKG. Refutes chest pain, palpitations, dyspnea, and orthopnea

Gastrointestinal: Normal appetite, no diarrhea, indigestion, reflux, vomiting, and nausea. Denies liver or gallbladder problem, jaundice. Regular bowel movement. No abdominal pain.

Genitourinary: Refutes vaginal discharge, itchiness, irritation, and discomfort. Denies pain or burning when urinating, suprapubic or flank pain hematuria, and dysuria. Repudiates hesitation or urgency to urinate.

Breast: Senses uneven lumps on her left breast, extremely aching on the outer, upper corner of her left breast

Musculoskeletal: Refutes pain on joints, muscles, and bones. Refutes constraint to a range of motion, weakness, stiffness and joint swelling

Extremities: No bony defect on the joints, heat or redness

Neuro/Psychiatric: Repudiates any trouble of concentrating or behavioural changes. Denies motor-sensory loss, seizures or fainting. Refutes hallucinations, suicidal ideation, mood swings, and depression.

Hematologic: Repudiates easy bleeding or bruising.

Endocrine: Denies kidney problems, thyroid problems, and a history of diabetes. Denies tenderness or thyroid enlargement, no inexplicable weight loss, or gain.

Objectives

Weight: 130 lb Temp: 96.9 F BP: 116/85

Height: 5.9” Pulse:60 Resp: 15

Constitutional: refutes night sweats, irritability, weakness, weight change, insomnia, anorexia, fatigue, chills, and fever

Mental status: Well-dressed patient who looks like her declared age. Seems to be hydrated and well-nourished and does not look to be intensely unwell. She is mild distress, oriented and alert.

Skin: the palms colour are normal for her ethnicity; they are warm. No clubbing observed — similar pigmentation. Great skin turgor. No nevi or rashes observed — scalp with no lesions. Hair texture is average. Nail beds pink; great capillary refill < 2 seconds. Moist mucus membranes and pink in the mouth.

HEENT:

Head : Head midline and erect. Smooth with no deformities, symmetric, atraumatic and normocephalic. Symmetric facial features. Hair of midline texture.

Eyes : Conjunctiva sclera white, pink. The lens and cornea are clear. Pupils are of equal size, regular and round, equally sensitive to the light like constricting and dilating, and bilateral accommodation. Intact peripheral visual fields. Intact extraocular movements. Present red reflex.

Ears : the obes do not have tenderness, lesions, or masses — clear bilateral ear canals. Tympanic membranes have good cone of light, intact and pearly grey. Hearing intact. Right perspicacity to whispered voice. Light reflex and bony landmarks envisaged bilaterally.

Nose : No polyps or discharge, mucosa moist and pink. Patent bilaterally and septum midline. No tenderness of sinus with palpation. The right and left nostrils differentiate dissimilar smells.

Throat : No tonsillar exudate or edema. Posterior oropharynx with no erythema. Midline uvula. Mucous membranes moist and pink with no ulceration. Gingiva firm and pink. Good dentition. Tongue midline, no tenderness or ulcers present.

Neck: No carotid bruits, trachea midline, the neck is supple.

Lymph Nodes: No lymphadenopathy on lymph nodes in the axillae and neck.

Cardiovascular: No overall cyanosis or edema. Heart sounds of S1 and S2 are audible with no gallops, rubs, or murmurs. No noticeable cyanosis or JVD. Equal pulses, bilateral in all extremes. No heaves, lifts, or thrills sensed on palpation.

Respiratory: Respirations regular rhythm and rate, equally bilateral, and non-laboured. No unilateral lag, struggle of breathing or extreme depth. Diminished lungs at the bilateral bases; clear to auscultation. No perceptible adventitious breath sounds, rhonchi, rales (crackles), or wheezes.

Chest/breast: No chest wall abnormalities. No reduced chest expansion or chest pain; symmetrical chest expansion. No barrel chest, localized rigidity or deformities. Percussion: no rise, fremitus, hyper resonance, or dullness. Palpation: no crepitus, tenderness, or abnormal tactile fremitus.

No skin changes, dimpling, symmetrical appreciated. Normal nipples. Multiple nodules on the left breast. Palpated-Superior tender mass, fluctuant, and lateral quadrant. Inferior tender mass, quadrant fluctuant and lateral.

Abdomen: Soft abdomen. No deep palpation, light or rigidity, tenderness or pain on other areas. Positive bowel sounds on auscultation in the quadrants. No venous hum, renal bruits, aortic or friction rubs. No ecchymosis, pulsations, ascites and masses. No splenomegaly or hepatomegaly.

Genital/Urinary: No protests of itching or vaginal discharge. No pain or burning during urination, suprapubic pain, flank, hematuria, or dysuria. No urgency or hesitation on urination. No bleeding during intercourse, discomfort, or pain.

Peripheral Vascular: Refutes bleeding or easy bruising.

Musculoskeletal:

Motor: Great tone and muscle bulk. Strength 5/5 all over. Gait steady. Intact point-to-point movements, Cerebellar Rapid alternating movements (RAMs).

Sensory: Romberg negative. Intact 2-point discrimination, vibration, position sense, light touch, and pinprick.

Reflexes: 2+ (brisk) plantar, Achilles, patellar, deep tendon reflexes of brachioradialis, triceps and biceps.

Psychiatric: appropriate behaviour for her age

Neurological: cooperative, oriented, alert, awake. Clear speech. Oriented to time, place as well as a person. Coherent thoughts. (Mertins, et al., 2016).

LABS&IMAGING

The latest mammography showed no evidence of mammographic malignancy. (BiRad2)

ASSESSMENT

Working diagnosis

Fibrocystic breast disease

Differential diagnosis

Mastitis, Fibroadenoma and breast cancer

Rationale

She has all progression and characteristics conforming with the disease.

Several breast lumps on the breasts; cyclic deviations, which deteriorate during menstruation. Mobile, tender, dominant lumps, Bilateral nodularity

PLAN

Labs and imagining studies:

US breast left, Mammogram Diagnostic Digital Bilat

Continuation with OB doctor as planned, the performance of ultrasound in the period of diagnosis and cancer.

Medications, immunizations therapies:

If mastitis will be observed, consume dicloxacillin 500mg PO QID antibiotics.

Education:

· Train the patient on how to do a breast self-exam.

· Call hospital is presence any fluid or augmented breast pain in nipple.

· Follow up and referrals

Reference

Mertins, P., Mani, D. R., Ruggles, K. V., Gillette, M. A., Clauser, K. R., Wang, P., ... & Kawaler, E. (2016). Proteogenomics connects somatic mutations to signalling in breast cancer. Nature, 534(7605), 55-62.

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