Breast Cancer Soap Note Sharon Broom January 17, 2020

Breast Cancer Soap Notename Sharon Broomdate January172020age 4

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 size and pain over the past week. The pain level is four out of ten. She reports no associated swelling, warmth, redness, nipple discharge, swollen glands, chills, or fever. Past Medical History includes fibrocystic breast disease, vitamin D deficiency, urinary tract infection, hypothyroidism, hypocalcemia, and constipation. She has had screening tests including a mammogram in 2016 (BiRad 2), normal Pap smear, and HPV test. She has a history of hysterectomy in July 2012 due to menorrhagia. Medications include Armour thyroid 30 mg, with a specific dosing schedule. She has allergies to Penicillin and Sulfa drugs. Family history notes her mother died of breast cancer before age 50, her father has hypertension, and her brother is healthy. Social history indicates she is divorced, lives with her son, does not smoke, drinks alcohol irregularly, and exercises regularly. She has not been sexually active for over a year and previously used condoms for contraception. She has not traveled outside the U.S. Recently, all childhood and adult immunizations are up to date.

Review of Systems: She denies fever, fatigue, chills, skin changes, visual or hearing issues, nasal congestion, throat issues, neck pain, respiratory or cardiovascular symptoms, gastrointestinal problems, urinary symptoms, or musculoskeletal pain. She reports tenderness and uneven lumps in her left breast. Neurological and psychiatric assessments are normal; no signs of cognitive or mood disturbances. No hematologic bleeding or bruising noted. Endocrine system appears normal. Weight is 130 lb, temperature 96.9°F, blood pressure 116/85 mmHg, height 5'9", pulse 60 bpm, respiration 15/min. She appears well, hydrated, well-nourished, with mild distress, oriented, alert, and speaks coherently.

Objective Examination: Skin appears normal with good turgor; no rashes or lesions. HEENT exam shows normal head, eyes, ears, nose, and throat findings with intact extraocular movements and bilateral visual fields. Ears are clear with normal tympanic membranes. Oral cavity reveals moist mucous membranes, good dentition, and no abnormalities. Neck is supple with no lymphadenopathy or thyroid enlargement. Cardiovascular exam shows regular heart rate and rhythm, no murmurs or edema, with symmetric pulses. Respiratory assessment reveals regular, non-labored breathing, with diminished lung sounds at bases but no adventitious sounds. Chest examination indicates symmetrical expansion with no deformities. Breasts show multiple palpable nodules on the left, with tenderness in the upper outer quadrant, fluctuant and mobile masses noted. The right breast is unremarkable. Abdominal examination is soft with positive bowel sounds, no tenderness, masses, or organomegaly. Genitourinary assessment indicates no vaginal discharge, pain, or urination issues. Peripheral vascular assessment is normal. Musculoskeletal exam shows full strength (5/5), normal gait, with intact reflexes and sensation. Neurological and psychiatric evaluations confirm alertness, proper behavior, and normal speech.

Laboratory and Imaging: Recent mammogram (2016) shows no evidence of malignancy. Planned ultrasound of the left breast to further investigate palpable lumps.

ASSESSMENT: The working diagnosis is fibrocystic breast disease with differential diagnoses including mastitis, fibroadenoma, and breast cancer. The patient's presentation with multiple mobile, tender lumps, cyclic variation, and no malignant features on prior imaging support fibrocystic changes. The familial history of breast cancer is notable and warrants close follow-up.

PLAN: Conduct ultrasound of the left breast and repeat mammography as scheduled. Consider biopsy if lesions persist or exhibit suspicious features. Manage symptoms with analgesics as needed. If signs of infection appear, initiate empiric antibiotics such as dicloxacillin. Educate the patient on breast self-examination techniques and warning signs of malignancy. Schedule follow-up appointments with the healthcare provider and refer to a specialist if necessary. Continue routine screening and monitoring of her breast health, considering her family history.

References

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