Soap Notenameamdate 03132020 Time 1000 Age 46 Yosexf Subject

Soap Notenameamdate03132020time1000age46 Yosexfsubjectivecc

SOAP NOTE Name: A.M. Date: 03/13/2020 Time: 10:00 Age: 46 y/o Sex: F SUBJECTIVE CC: “I felt something hard in my left breast while showering” HPI : This is a 46-year-old, African American woman who presented with a concern about a palpable mass detected in her left breast five days prior during showering. She reports fear of re-examination but denies associated pain, skin changes, nipple discharge, fever, or chills. Her last menstrual period was on 02/28/2020. Her medical history includes routine mammograms and Pap smears, which have been consistently normal, and a significant family history of breast cancer on her maternal side, including her aunt diagnosed at age 52. She does not currently use contraception. Her medications include omeprazole, diclofenac, emgality, multivitamins, vitamin C, and calcium. Past illnesses include migraine, dysmenorrhea, and GERD; immunizations are up to date except for Gardasil. She has allergies to sulfas and no known medication intolerances. Surgical history includes a C-section in 1999. She is G2T1P0A1L1. Her social habits involve moderate alcohol intake, no recreational drugs or tobacco, and consistent use of sunscreen. Her family includes her mother (alive, 69, with Parkinson’s), her father (deceased, pancreatic cancer), and a maternal aunt with breast cancer. She has one healthy son.

ROS reveals weight gain of approximately 15 pounds over the past year, fatigue around her periods, and breast tenderness pre-menstrually. She denies systemic symptoms such as fever, chills, or significant respiratory, gastrointestinal, or cardiovascular complaints. She reports occasional gastric reflux and menstruation characterized by regular cycles, last bleeding on 02/28/2020. She also reports pelvic bloating and pain prior to periods, but no urinary or vaginal symptoms. Her breast exam confirms a mobile, superficial, well-defined, round mass measuring 2.5 cm in the upper outer quadrant of her left breast without skin changes or axillary lymphadenopathy. The right breast appears normal. The rest of the physical exam is unremarkable, with vital signs within normal limits and no other notable findings.

Paper For Above instruction

This case involves a 46-year-old woman presenting with a palpable breast mass detected incidentally during showering. The assessment emphasizes differentiating benign breast lesions like fibroadenoma from malignancies such as breast cancer, determining appropriate diagnostic workups, and formulating a management plan.

The patient's presentation—a firm, mobile, painless lump, with long-standing normal mammograms and negative family history, primarily raises suspicion for a benign breast tumor such as a fibroadenoma. Fibroadenomas are common in women in reproductive years, displaying characteristic features including well-circumscribed, smooth, mobile masses. They generally do not increase the risk of breast cancer, but given her family history, further evaluation is warranted.

In breast assessment, distinguishing benign from malignant lesions necessitates imaging studies. This patient’s recent mammogram was normal, but the density of her breasts and family history justify further imaging—namely, breast ultrasound and possibly diagnostic mammography—to evaluate the lesion further. Ultrasound can elucidate the lesion's characteristics—whether cystic or solid, margins, and vascularity—thus guiding diagnosis and management.

Given her clinical presentation and physical exam, the most probable diagnosis is fibroadenoma (ICD-10 D24.2). These benign tumors are composed of stromal and epithelial tissues, tend to be mobile, painless, and have well-defined borders. Nonetheless, differential diagnoses include breast cysts, carcinoma, and other benign tumors such as papillomas or phyloid tumors. Malignant breast tumors generally present as irregular, fixed, and often tender masses, sometimes with skin or nipple changes. The absence of these features, her negative family history for malignancy (apart from her aunt), and benign imaging findings favor a benign diagnosis.

The management approach includes reassurance, patient education, and surveillance. Since her ultrasound and mammogram findings are consistent with a fibroadenoma, conservative management is appropriate unless the lesion increases in size or develops suspicious features. Regular follow-up with clinical breast exams and imaging as indicated is essential. If the lesion persists after 6–12 months or enlarges, surgical excision or biopsy may be considered, especially given her family history of breast cancer.

Therapeutically, continuation of routine screening mammography is advisable, with annual or biennial intervals depending on guidelines. The patient should perform monthly self-examinations and report any changes promptly. Lifestyle modifications—including weight management, balanced diet, avoidance of smoking, and minimization of alcohol intake—can reduce overall breast cancer risk. Use of sunscreen and protection from UV exposure should be emphasized.

In addition, counseling regarding reproductive health and the implications of her family history is necessary. Since she is not using contraception and is of an age where pregnancy could pose some risk, discussing family planning options might be beneficial. Although her current reproductive status does not suggest the need for hormonal interventions, she should be made aware of the implications of pregnancy risks in her age group.

This case underscores the importance of a comprehensive approach combining clinical examination, appropriate imaging, patient education, and vigilant surveillance for benign versus malignant breast lesions. Given her familial risk, close follow-up is critical for early detection of any malignant transformation, and ongoing education about self-awareness remains paramount to optimizing her health outcomes.

References

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