SOAP NOTE
Women’s Health / Primary Care SOAP
Age Range: 25- 30 Gender: Female
Occupation: Receptionist
Subjective:
ID: M.L.
Reliability: Patient is a knowledgeable and a reliable source of information.
Reason for seeking Care (CC): Complaint of heaviness and pain in the left breast on and off since the last 4 months.
History of Present Illness: Not applicable. No history of change in surgical, medical or family history.
Travel History past 30 days: No history of travelling in the last 30 days.
Current Medications: Denies being on any medication currently or in the past.
Allergies (Medication, Food, Environmental): Not allergic to any medication, food or environmental influences.
Immunizations: Received all the immunizations in a timely manner.
History of Present Illness: The patient was apparently well four months back when she gradually developed pain in her left breast. With progressing time, she felt a palpable mass in the left breast which appeared to be of the size of a cherry.
Past Medical History: Childhood illness: Typhoid at the age of 15 years, Leg fracture at the age of 18 years. Adult Illness: Nil Medical History: No significant medical history Hospitalizations: Nil
Surgical History: Nil Sexual History: Patient is presently sexually active in a mutually monogamous heterosexual relationship with her partner of 2 years. Patient is contended with her sexual relationship and partner. She denied using any OCP or condom. She denied using any other method to prevent pregnancy or STDs. No dyspareunia. Total number of lifetime partners is 2.
OB/GYN: G P (TPAL): G0 T0 P0 A0 L0 Last Breast Exam: 07/28/2015. Normal Last Mammogram: N/A d/t age Last Pelvic Exam: 07/28/2015. Normal Last Pap/ Results/Treatment: 07/28/2015. No abnormal findings. LMP: 3/02/16 Menarche: 12 Coitarche: 16 History of HIV&STDs: No history of STD.
Contraception: None in use at the moment. Self-Breast Examination (SBE): Occasionally performs monthly self-breasts examinations which revealed presence of a nodular mass in the left breast of the size of a cherry Psych History: None Family History: Mother is a diagnosed case of diabetes (diagnosed at the age of 42). Father has heart disease and had an attack of angina pectoris 2 years back. He underwent angioplasty and has two stents placed in his left coronary artery. She has one sister who is apparently well. No other family member reported to have suffered from any serious disease.
Social History: She is a complete teetotaller. Never smokes. No drug addiction.
Harm Assessment: She applies sunscreen every time she leaves home. Home Safety: She stays with her parents and a sister. There are no familial discords and family environment is happy and peaceful.
Sleep: Sleeps for 8- 9 hours per day. Feels refreshed on waking up. Physical Activity: Visits gym every morning and works out for 1.5 hours daily.
Diet: Takes 3 meals a day. Mostly takes non vegetarian food. Depression Screen: No sign of depression noticed. She is a calm and cooperative person.
Review of Systems: was completed by preceptor with student observing
General: No fever, no chills, no fatigue and no weight fluctuations.
Skin, Hair, & Nails: No visible changes in moles, no rashes, no pruritis, no lesions and no apparent hair loss. No change in skin texture and pigmentation. No change in the appearance of nail.
Breasts: No warmth on touch, slight tenderness, no erythema. No dimpling of skin. A cherry sized swelling in the left breast.
Respiratory/Thoracic: No cough, no wheezing, no shortness of breath, no dyspnea at rest or on exertion.
Cardiovascular: No chest pain, no palpitations, no tightness or discomfort. No arrhythmia or murmur.
Peripheral Vascular: No edema in any of the extremities, no pain or paresthesia, no warmth, no coolness (normal ambient temperature), no thrombosis.
Gastrointestinal/Abdomen: No nausea, no vomiting, no diarrhea, no constipation. No evidence of any dyspepsia, no blood in stool or changes in stool. No evidence of any abnormally excessive pain during menses.
GU/OB/GYN: Symptoms as per cc and no irregularities with menstrual cycle. No genital lesions, bumps, lumps, or pain during intercourse. No history of sexual abuse, rape, and domestic violence.
Urinary: Denies urinary frequency, urgency, burning, decreased stream, hematuria and foul smelling urine. Reports history of urinary tract infections in past.
Hematological: No history of anemia, no spontaneous or easy bruising and/or bleeding. No prolonged or excessive bleeding, no purpura or petechiae. No history of transfusions or syncope.
Endocrine: No change in appetite, no polyuria, no polydipsia and no polyphagia. Patient is ambithermal, no intolerance to any extreme of temperature.
Psychiatric: No history of anxiety, no depression, no personality disorders, no hallucinations, no bipolar or suicidal ideations and attempts in the past.
Objective:
VS: BP- 120/80, HR -69, RR-18, Temp-37.4. Pain 0/10 (verbal pain scale). Vital statistics taken by office staff nurse. Weight: 244lbs. Height 65.5in. BMI-37.5 (overweight). Vision: 6/6 Normal, both eyes. Urinalysis: Clarity- transparent. Color- pale yellow. Glucose- Nil. Bilirubin – Nil. Ketones – Nil. General Statement: No signs of distress or of emergent conditions noticed. Skin: normal skin according to ethnicity, normal temperature and normal texture. Affect and mood appropriate. Dress, hygiene, and grooming appropriate and without odor.
Patient has a smooth and steady gait. She appears her age.
Mental Status: Patient is alert and well oriented x3. Cooperative. Speech is clear, coherent, and no slurring.
Physical Exam:
Head: Normocephalic, no lumps and no bumps. Hair is of burgundy color, with smooth texture and are evenly distributed.
Abdominal: Soft, non- tender, spleen and kidneys are not palpable. Aorta is not palpable. Normal bowel sounds present in all the 4 quadrants. No masses palpable in the abdomen. No distention of abdomen. No CVA tenderness.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2. No murmurs, no gallops, or rubs. No peripheral cyanosis or edema
Breast: Slight pain, a palpable lump noted in the left breast in the left upper quadrant. No nipple discharge. Lymph nodes impalpable, slight tenderness of the left breast. The palpable mass is rubbery in consistency and is of 2cm in length and 3cm in breadth. No tenderness of the right breast. Breasts symmetrical, with no dimpling, nipples everted.
Pelvic: No significant finding.
Rectal: Deferred
Working Diagnosis: Fibroadenoma Breast: The most probable diagnosis for this case can be Fibroadenoma breast as many symptoms of the patient resemble those of fibroadenoma. The age of onset, nature of pain and features of the palpable mass point towards the probability of this disease condition (Mayo Clinic Staff, 2016).
Differential Diagnosis: 1) Breast cancer: The symptoms may correspond to the initiation of breast cancer. The fact that this disease condition is extremely dangerous, makes it highly important to be ruled out first.
2) Fibrocystic condition: Very similar manifestations. But the differential features lie in the fact that in fibroscystic condition of the breast the pain and size of the swelling fluctuates with the menstrual cycle (Cheung, 2010).
3) Breast abscess: This is again a painful breast swelling. But the features are different from that of the patient as breast abscesses are characterized by redness and heat of the mass whereas, this mass does not show such features (Nhs.uk, 2016).
Plan: Interventions: 1) The patient was encouraged to continue undergoing self breast examination as often as possible
2) The patient was advised to visit the physician as soon as she notices any change in the swelling in terms of size, temperature, texture and color. 3) Encouraged to keep her brassieres clean and sleep without putting them on.
Diagnostics
1) Mammogram
2) Biopsy following the results of mammogram.
Prescriptions and Therapeutics: As the condition is relatively harmless and mostly self limiting, it would be ideal to wait and watch the condition. In case the condition becomes more problematic the patient may be required to undergo lumpectomy. Otherwise, for controlling pain general NSAIDs will suffice.
Referrals: None
Follow-up: 1) Telephone or office follow-up in 15 days to assess the condition of the lump. 2) Return to clinic if there is any noticeable change in the lump. 3) Routine follow-up not needed if symptoms resolve.
Reflection: Fibroadenoma breast is a relatively harmless condition and is mostly self limiting. The condition becomes problematic only if the size becomes too large to cause regional pain or causes disfigurement. The treatment should usually confine to wait and watch policy, the chances are high that the condition will resolve on its own. The pain can be managed with the help of some anti inflammatory medicines.
My goals for next week is to educate myself more on the various diagnostics and gynecologic visit schedules.
Medication List: 1) Ibuprofen: 400mg orally, every 4- 6 hours
Indicated: in generalized pain
Side effects: Anemia, bleeding, Vomiting
2) Naproxen: 550mg orally, after every 12 hours Indicated in inflammatory conditions
Side effects: Rashes, dyspnea.
References
Breast abscess - NHS Choices. (2016). Nhs.uk. Retrieved 15 April 2016, from http://www.nhs.uk/Conditions/Breast-abscess/Pages/Introduction.aspx
Cheung, K. (2010). Breast Lump/Mass. Errolozdalga.com. Retrieved 15 April 2016, from http://errolozdalga.com/medicine/pages/KC/BreastLump.mass.ck.8.2.10.html
Mayo Clinic Staff,. (2016). Fibroadenoma Symptoms - Mayo Clinic. Mayoclinic.org. Retrieved 15 April 2016, from http://www.mayoclinic.org/diseases-conditions/fibroadenoma/basics/symptoms/con-20032223
