Posted: May 1st, 2022

Soap Note essay

SOAP NOTE
Determine: M.W Date: 11/02/2018 Time: 10:00 AM
Age: 25 y/o Intercourse: Female
SUBJECTIVE

CC: “I’ve a lump on my left breast”

HPI: Affected particular person is a 25-years-old White Hispanic Female The affected particular person obtained right here to the office complaining a couple of mass inside the left breast from 2 week previously. The lump was observe whereas she was having a bathe. The affected particular person denied ache in that breast, nipple discharge, or change inside the in shade or look of the pores and pores and skin. The affected particular person is anxious in reference to the findings. Gynecologic historic previous menarche: on the age of 11, with rhythm 28 x three, denies any STDs, G0P0A0L0, sexual energetic, one confederate.

Medicines: No.
PMH: Denies
Allergic reactions: Denies any allergic reactions to meals or drugs
Drugs Intolerances: Denies.
Primary traumas: Denies any trauma
Hospitalizations: Denies hospitalizations
Surgical procedures: Denies Surgical procedures

Family Historic previous
Mother: Alive, Diabetes Sort II.
Father: Alive,CAD
Brothers: 1 Alive and Healthful
Children: None.

Social Historic previous:
Residence kind: Residence
Marital standing: Single
Religion: Denies.
Tattoos: no
Alcohol: Denies
Treatment: Denies
Smoker: Non smoker
Prepare: 30- 45 minutes of stroll three cases 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 3 days, widespread cycle, plus the spots already described, G0T0P0A0L0, Supply Administration: Certain/condom.
ROS
Widespread
Denies any weight change inside the remaining earlier 6 months denies weak spot, fatigue report month-to-month, not fever or chills. No distress well-known at this second, responding question in an appropriated mood. No practice intolerance. Cardiovascular
Affected particular person denies chest ache and palpitation. No edema noticed no syncope, no orthopnea.
Pores and pores and skin
Warmth and dry, pores and pores and skin is appropriated shade for ethnicity. Respiratory
Affected particular person denies cough, dyspnea, wheezing or hemoptysis, no acute distress 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 conduct modifications, no melena, no constipation.
Ears
Denies ear ache, listening to 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 energetic, Heterosexual, denies STI’s, Menarche: 11 y/o, LMP: 10/15/2018 for 3 days, widespread cycle, plus the spots already described, G0T0P0A0L0. Sexual energetic, one confederate.
Nostril/Mouth/Throat
Denies challenge in smelling, sinus points, nostril bleeds or discharge. Denies dysphagia, hoarseness, or throat ache. Musculoskeletal
Denies cramps, joint stiffness, arthritis or gout, limitation of movement, historic previous of musculoskeletal or disk illnesses; denies any muscle or joint ache.
Breast
Robust mass inside the left breast. Denied nipple discharge, breast ache or change inside the breast pores and pores and skin. Neurological
Denies historic previous of problems, syncope, seizures, stroke, memory dysfunction or mood change. No weak spot, paralysis, numbness/tingling, tremors or tics, involuntary actions, or coordination points. No psychological issues or hallucinations.
Heme/Lymph/Endo
Denies easy bruising or bleeding. No historic previous of anemia, blood transfusions or reactions. Denies publicity to toxic brokers or radiation. / Denies heat or chilly intolerance, excessive sweating, polydipsia, polyphagia, or polyuria. No historic previous of diabetes, thyroid sickness, or hormone various.
Psychiatric
Denies despair, memory modifications. Denies suicides makes an try or concepts. No historic previous of psychological illness.

OBJECTIVE
Weight: 125 lbs
BMI: 22.1 Temp: 98.7 F BP: 100/64 mm/Hg
Ache: zero/10
Prime: 5’three’’ inch Pulse: 74 bpm RR: 18 bpm
O2 Saturation: 99 % at Room air
Widespread Look
Affected particular person is a 25 y/o WHF, displaying of staged age; Alert and oriented; options questions appropriately. No acute distress presently. AAOX4, PERRLA; options questions appropriately. Ache stage: zero/10 on scale of ache.
Pores and pores and skin
Widespread look is common. Common temperature, Hydrated, no rashes or lesions described. Intact, warmth, moist, good turgor. Screening for pores and pores and skin most cancers carried out no precancerous pores and 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 grey with constructive delicate reflex; landmarks merely visualized. Nostril: Nasal mucosa edematous, clear rhinorrhea, cheap 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. Widespread rhythm and payment with S1, S2 common, 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 well-known presently.

Gastrointestinal
Abdomen Delicate, non-tender, BS common in all 4 quadrants. No hepatosplenomegaly, mass, or herniation
Breast
The breast tissue, nipples, and areas throughout the breast with common look. Type and dimension are common. A small spherical mass (three.zero cm) is palpable inside the left breast with distinct borders, company tissue, merely moved and painless localized at three – 4:00. There was no nipple discharge or retraction. No axillary nodes.
Genitourinary
Genitalia:
Often developed female genitalia. No perineal or perianal abnormalities are seen. No genital lesion or urethral discharges. No well-known introitus discharge or irritation.
Speculum examination: No vaginal partitions bleeding, no cervix discharge, erythema, or friability. Bimanual examination: Mobile cervix, not painful. No adnexal lots or tenderness. No pelvic ache.
Musculoskeletal
Common gait, no limping or musculoskeletal deformities, or muscular atrophy. Thoracic and lumbar spine, common. Full ROM in all 4 extremities, no joint stiffness.
Neurological
Speech clear. Good tone. Posture erect. Steadiness regular; common gait.
Reflexes 2+ bilaterally all by.
CN II-XII intact.
Psychiatric
Logic. Alert and oriented. Sporting clear skirt and shirt. Maintains eye contact. Speech is delicate, though clear and of standard payment and cadence; options questions appropriately.
Lab /Checks/Screening/Intervention/Analysis:
1.- Bilateral whole-breast US, (ordered)
2.- Mammography (Mammogram), (ordered)
three. – CBC, BMP, U/A Reflex to custom. (ordered)
Intervention
1. Calculated BMI / in common parameters
2. Counseling about bodily train (practice)
three. Ache severity zero/10
4. Documentation of current medication (course of)
5. Grownup despair screening analysis
Explicit Checks
Not carried out.
Assessment
Assessment:
1. Benign Neoplasm of Left Breast – (D24.2) as proof by small spherical mass (2.zero cm) is palpable inside the left breast with distinct borders, company tissue, merely moved and painless, localized at three – 4:00 Hrs. No axillary nodes.

DIFFERENTIAL DIAGNOSTIC:
1. Malignant Neoplasms of the Breast: Breast most cancers is a malignant tumor that varieties from the uncontrolled progress of irregular breast cells. Malignant tumors can invade and destroy surrounding tissue and unfold to totally different parts of the physique. Breast most cancers usually impacts tissues involved in milk manufacturing (ductal and lobular tissues).
2. Fibrocystic Breast Sickness: The scenario is kind of widespread and benign, which implies that fibrocystic breasts is not going to be malignant (cancerous). Fibrocystic breast sickness (FBD) is now referred to as fibrocystic modifications or fibrocystic breast scenario, is the most common motive behind “lumpy breasts” and impacts higher than 60% of women.
three. Lipoma of the Breast: A lipoma is a benign tumor of the breast. So, fat tissue is the first a part of a lipoma. Primarily, a lipoma is a pocket of fat that is encapsulated by a thin fibrous capsule. Lipomas are fairly widespread and should occur in numerous areas of the physique.

Plan/Therapeutics & Education:
Medicines: No drugs is ordered.

Educating/Education:

Dietary modifications (stay away from caffeine, alcohol).
You could perform a month-to-month breast examination on the an identical time each month, 1 week after your menstrual interval ends.
Return to the office when you occur to uncover any new breast modifications in dimension, type, or contour of the breast. If a model new node appears. Moreover, when you occur to watch a change inside the look or actually really feel of the pores and pores and skin and nipple. Return when you occur to watch spontaneous bloody or clear fluid from the nipple. Reduce or stay away from caffeine and soy merchandise.
Sickness course of: Fibroadenomas are a benign neoplasm of the breast that always develop inside the youthful women, between the age of 15 and 35 (Poter, 2011). The tumors are usually additional circumscribe and mobile and, when palpated, may actually really feel like small, slippery marble (Llanio-Navarro & Perdomo-Gonzales, 2003). The exact causes are unknown nonetheless, enchancment of fibroadenomas may relate to reproductive hormones. Tumors may shrink after menopause, when hormone ranges decline (Poter, 2011).
Non-medication cures: NA

Adjust to-ups/Referrals:
* Affected particular person should return to clinic in three weeks to evaluate the outcomes of breast ultrasound, Mammography (Mammogram), and CBC, BMP, U/A Reflex to custom.
* Adjust to Dr. orders and in case of emergency please identify 911 or come to nearest ER.
* Adjust to up in two weeks to evaluated affected particular person and laboratory testing outcomes.
* No referrals wished presently.

Assessment of affected particular person encounter:
Interview course of went correctly, practitioner elaborated the plan of care with affected particular person, and education was equipped and verbalized understanding.
A palpable breast mass is the most common discovering of symptomatic breast most cancers. Assessment of a breast mass begins with an in depth historic previous, analysis of breast most cancers menace, and bodily examination and requires age-appropriate breast imaging. Breast lots are frequent and typically benign. Certain qualities of a mass (e.g. mobile, unattached to surrounding tissue, discrete, simple ground) are reassuring to the provider mass in a youthful woman is benign. Primarily based totally on the historic previous and bodily examination, the provider can normally make the proper prognosis of benign or malignant nonetheless not basically to the diploma that is reassuring for the provider and/or the affected particular person.2 Cyst aspiration and cytology of the fluid is utilized in a additional restricted development and primarily only for greater, bothersome simple cysts. If aspiration is completed, the fluid is non-bloody and the mass is gone, simple shut follow-up is appropriate. If the mass would not utterly resolve, recurs or the fluid is bloody with aspiration, a tissue biopsy is indicated. Inside the setting of a mass seen as secure on ultrasound, further imaging and sure biopsy may be merited. When imaging is ordered inside the setting of a breast criticism, it must be diagnostic and by no means screening. Counting on the imaging unit, they could immediately proceed with out additional orders to secondary imaging and even biopsy as indicated by the classification of the preliminary footage. Suppliers ought to concentrate to the reporting and diagnostic steps of the imaging group and be sure that subsequent tales are tracked, and follow-up is carried out.

References:
Bickley, L. S. (2013). Bates’. Info to bodily examination, (11th ed.). Philadelphia, PA: wolters Kluwer Lippincott Williams & Wilkins.
Cash, J. C., & Glass, C. A. (2014). Family observe ideas (third ed.). New York, NY: Springer Publishing Agency.
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 Agency.
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 Degree, P

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