Breast Cancer SOAP Note

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Breast Cancer SOAP Note

(Breast Cancer 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 History:
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 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 and wears sunscreen.

Sexual/Contraceptive History:

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

Travel History:

She has not traveled out of the U.S.

Immunizations: (Information missing)

Review of Systems (ROS)

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, or 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, or nausea. Denies liver or gallbladder problems, 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 with concentrating or behavioral 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.

OBJECTIVE

Vitals:

  • Weight: 130 lb
  • Temp: 96.9 F
  • BP: 116/85
  • Height: 5’9”
  • Pulse: 60
  • Respiration: 15

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

Skin:
Normal for ethnicity, warm. No clubbing, rashes, lesions, or abnormal pigmentation. Good skin turgor.

(Detailed HEENT, Cardiovascular, Respiratory, Chest/Breast, Abdomen, Genital/Urinary, Musculoskeletal, Neurological, and Psychiatric findings remain unchanged).

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 & Imaging Studies:

  • Ultrasound of left breast
  • Mammogram Diagnostic Digital Bilateral
  • Follow-up with OB doctor, perform ultrasound for diagnosis and cancer screening.

Medications & Immunizations:

  • If mastitis is observed, prescribe Dicloxacillin 500mg PO QID antibiotics.

Patient Education:

  • Train the patient on how to perform a breast self-exam.
  • Call the hospital if there is any fluid or increased breast pain in the nipple.
  • Follow up and referrals as needed.

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 signaling in breast cancer. Nature, 534(7605), 55-62.

 
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