NRP/560 Version 3 / 1
University of Phoenix Material
Week Five Case Study
SOAP Note: ABNORMAL BREAST FINDING
PATIENT INFORMATION:
MS
47 YO female
CURRENT MEDS:
Premarin .625 mg 1 QD
SOCIAL HISTORY:
Smoker 1 ppd X 20 years
ETOH/Drug use – neg
Married with 2 children
Husband self employed – without benefits
Housewife – no insurance
PAST MEDICAL HISTORY:
Complete hysterectomy at age 37 for persistent abnormal pap smears
FAMILY HISTORY:
Heart: Father MI age 51 – alive at age 68 (triple bypass)
DM: Mother DMII @ age 45 – oral meds currently
Sister: Breast cancer age 35. Relapse X 6 months ago – prognosis grim
First visit to your
SUBJECTIVE:
Mrs. S is a 47 year old female who comes to your office because she has noticed a lump in her breast. She states she noticed the lump about a year ago – but she has no insurance, so has just been watching it. She comes to you today as she has noticed that it has gotten larger. She denies any other signs and symptoms, but is quite anxious and tearful. Her last mammogram was done over 5 years ago, and was negative.
OBJECTIVE:
HT: 5’8”
WT: 160 lbs
BP: 130/70
P: 80
HEENT: Normal
Neck: Thyroid non-palpable
Heart: RRR, S1 S2, without murmur
Lungs: Clear
Breasts: Pendulous, some bilateral nodularity noted
L breast – 2.5 cm, fixed, nontender nodule noted in the LUOQ. Some dimpling in
That area. Axillary nodes palpable. Infra and supraclavicular nodes non palpable
Abd: BS normal. Soft, no organomegally, no aortic bruit
EG: No lesions noted. Normal hair pattern, BUS normal
Vagina: Scant, clear d/c – no signs/symptoms
Cx/Uterus – Absent
Adnexa: No palpable masses
Rectal – No palpable masses, Neg occult blood
ASSESSMENT:
Gyn exam
L Breast nodule
PLAN:
Pap smear of vaginal cuff done
Referral for mammogram and US as needed.
Referral list of providers given
Explained the need for diagnostics ASAP to determine further follow up
Premarin .625 mg Sig: 1 PO QD
Pt. Tearful, but voiced understanding
RTC following mammogram for consultation and follow up plan
Follow up visit to your office 2 weeks later
Consultation:
Mrs. S, a 47 year old female returns to your office to discuss her mammogram and ultrasound results. The results reveal a solid, suspicious nodule. The impression on the mammogram report reads, “These findings are highly suspect for a malignant process and further evaluation is suggested with biopsy”. Mrs. S just falls apart in your office. She has to teenage sons and doesn’t want to die.
You are to write a SOAP note addressing Mrs. S’s health issues, further evaluation, referral, and treatment. Also discuss how you will manage her psychosocial, medical and preventative issues related to her potential diagnosis. This patient has no insurance, address how you will assist her in obtaining care.
Please keep in mind, you just did a complete exam less than a month ago.
You may use the same template you have used in prior classes with your plan and rationale being listed side by side. Please use references when applicable.