Breast Cancer SOAP note
Name Sharon Broom
Age: 45 years old
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.
Past Medical History:
Fibrocystic breast disease, Vitamin D deficiency, Urinary tract infection, Hypothyroidism, Hypocalcemia, and Constipation
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)
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
Food allergies, Penicillin Triple Sulfa Vaginal CREA
The patients mother passed away at the age of fifty, with a medical history of breast cancer. Sharons 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.
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.
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.
She has not travelled out of the U.S.
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 he
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