SOAP NOTE for Medical Evaluation of Breast Lump ✓ Solved
SOAP NOTE
Name: M.W
Date: 11/02/2018
Time: 10:00 AM
Age: 25 y/o
Sex: Female
SUBJECTIVE
Chief Complaint: “I have a lump on my left breast.”
History of Present Illness: The patient is a 25-year-old White Hispanic female who presented with a complaint of a mass in the left breast, noticed two weeks ago while taking a shower. The lump is not associated with pain, nipple discharge, or any changes in skin color or appearance. The patient expresses anxiety concerning her findings.
Gynecologic History: Menarche at age 11, regular menstrual cycle (28 days), G0P0A0. The patient is sexually active with one partner and denies any STDs.
Medications: None
Past Medical History: Denies any major trauma, hospitalizations, or surgeries. No known allergies.
Family History: Mother alive with Type II Diabetes, father alive with coronary artery disease, one healthy brother, no children.
Social History: Single, living in an apartment, denies substance use, exercises 3 times a week.
Review of Systems: Denies weight change, fever, cough, gastrointestinal symptoms, urinary symptoms, and significant neurological issues.
Objective Findings:
Weight: 125 lbs, BMI: 22.1, Blood Pressure: 100/64 mm Hg, Pulse: 74 bpm, Respiratory Rate: 18 bpm, O2 saturation: 99% on room air.
General Appearance: Patient appears well-nourished and developed for age, alert, oriented, and in no acute distress.
Breast Examination: Notable for a small, round mass (3.0 cm) in the left breast, firm but painless with distinct borders, located at 3-4 o’clock. No nipple discharge or axillary nodes noted.
Plan:
1. Bilateral whole-breast ultrasound.
2. Mammography.
3. Complete blood count and basic metabolic panel.
4. Patient education regarding monthly breast self-exams.
Assessment: Benign neoplasm of the left breast, differential diagnosis includes malignant neoplasm, fibrocystic breast disease, and lipoma.
Follow-up: Patient advised to return for evaluation in three weeks or sooner if symptoms worsen.
Paper For Above Instructions
The SOAP note for M.W., a 25-year-old female who presented with a complaint of a lump in her left breast, captures a comprehensive view of her subjective and objective health evaluation.
Chief Complaint and Medical History
The patient reported the discovery of a lump in her left breast two weeks prior to the visit. She noticed the mass while showering, and it has caused her increasing anxiety. Importantly, she denied any associated pain or discharge, which might suggest a more severe underlying pathology. Her gynecological history is unremarkable, with menarche occurring at age 11 and no history of STDs. She is sexually active with one partner and has no children, reported as G0P0A0.
Social and Family History
M.W. leads a healthy lifestyle, exercising regularly and denying the use of tobacco, drugs, and alcohol. Her family history includes a mother with Type II diabetes and a father with coronary artery disease, though no malignancies have been previously reported, which provides a context sensitive to hereditary risks.
Objective Findings and Examination Results
During the physical examination, M.W. is observed to be in no acute distress with normal vital signs. The breast examination revealed a palpable mass in the left breast, with distinct edges, suggesting a benign etiology. The lack of associated symptoms such as discharge or lymphadenopathy further aligns with a benign condition like a fibroadenoma or lipoma, potentially diminishing the likelihood of malignancy.
Assessment and Differential Diagnosis
The rolling assessment classified the findings as a benign neoplasm of the left breast, specifically citing the mass's mobility and characteristics as indicative of non-malignant tissue growth. The differential diagnosis included:
- Malignant Neoplasms of the Breast: Breast cancer remains a foremost concern, particularly among young women.
- Fibrocystic Breast Disease: This common benign condition presents with lumpy breasts and is prevalent in women.
- Lipoma of the Breast: A benign fatty tumor that typically poses no health threat.
Plan and Education for Care
To confirm the diagnosis and address patient concerns, a bilateral breast ultrasound and mammography have been ordered. M.W. is informed about the importance of self-breast examinations to monitor changes and recognize abnormal masses early. Lifestyle adjustments, including avoiding caffeine and routine health screenings, are highly advised.
Conclusion
In summary, M.W.'s clinical presentation is thoughtfully assessed through the SOAP note format, prompting a structured plan to ensure timely investigations into her breast lump. Regular follow-ups and education empower the patient regarding her health, particularly regarding the critical aspect of breast health monitoring.
References
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