NUR MISC Breast Cancer SOAP NOTE

NUR MISC Breast Cancer SOAP NOTE Running head: SOAP NOTE 1 NUR MISC Breast Cancer SOAP NOTE Breast Cancer SOAP NOTE Name Institutional Affiliation Date grade_benderSOAP NOTE 2 SOAP NOTE Name: HH Date: 30/09/2019 ...

NUR MISC Breast Cancer SOAP NOTE Running head: SOAP NOTE 1 NUR MISC Breast Cancer SOAP NOTE Breast Cancer SOAP NOTE Name Institutional Affiliation Date grade_benderSOAP NOTE 2 SOAP NOTE Name: HH Date: 30/09/2019 Time: 10.30pm Age: 29 Years Sex: Female SUBJECTIVE CC: “I have a swollen breast with a lump and I feel pain around my nipple that has discharge.” HPI: Patient is a 29-year-old Hispanic female who comes to the clinic with breast pain, nipple pain and discharge. Additional complains reported are breast lumps felt by the patient. Patient denies trauma that may be causing the pain. Pt. adds that the nipple has retraction and there is skin dimpling around the breast. Patient reports of thickening and redness of the skin around the breast. Patient reports that this has been happening for four months now. Denies other symptoms such as headache, constipation or abdominal pain. Denies having used any medication to treat the symptoms. Medications: None PMH Allergies: No allergies reported Medication Intolerances: None Chronic Illnesses: None grade_benderSOAP NOTE 3 Hospitalizations: None Family History Patient’s mother has breast cancer which is under pharmacological maintenance. Father has type II diabetes which is also under management with lifestyle modification and proper nutrition. Patient does not have other siblings. Social History Patient works at a nearby bakery and walks from home to work every day apart from weekends. Patient is not married and lives with her parents. Reports to have no kids. Denies smoking, drinking alcohol or drug abuse. ROS General Denies changes in energy levels and weight status. Denies sweating at night, fever or chills Cardiovascular Denies palpitations, chest pain or edema. Skin Denies skin changes such as discolorations of the skin, lesions, rashes or delayed healings. Respiratory Denies breathing difficulties, coughing or a pneumonia or TB history. grade_benderSOAP NOTE 4 Eyes Patient does not wear corrective lenses and denies eye discharge, loss of vision or changes in vision. Gastrointestinal Denies pain in the abdomen, constipation, ulcers or black tarry stools. Denies eating disorders. Ears Denies loss of hearing, hearing changes, ear discharge or ear pain. Genitourinary/Gynecological Patient denies dysuria, polyuria or increased frequency of urination. Denies an STD history and has not had any PAP tests before. Denies being on any contraceptives. Denies vaginal discharge and also denies being pregnant before. Nose/Mouth/Throat Denies complications of the sinus, nose bleeding or dysphagia. Denies dental illness, throat pain or hoarseness. Musculoskeletal Denies joint stiffness, tenderness or pain. Denies back pain. Breast Positive for lumps, skin dimpling and nipple retraction. Reports of breast pain on Neurological Denies fainting, seizure or weakness. Denies black out spells or paresthesias. grade_benderSOAP NOTE 5 the left breast. Positive for redness and scaling around the skin. Patient reports of general breast discomforts. Heme/Lymph/Endo Denies blood transfusion, swollen glands or night sweats. Denies increased hunger or thirst. Denies intolerances of heat or cold. Psychiatric Denies anxiety, depression, suicidal ideations or attempts. Denies serious sleeping difficulties. OBJECTIVE Weight 132lbs BMI Temp 98.1 BP 121/61 Height 5’5” Pulse 78 Resp 18 General Appearance Patient is a healthy appearing adults who is well developed and well-nourished in no acute distress. Answers questions correctly. Skin Skin is normal with no rashes or lesions noted apart from the skin around the breast that has dimpling and cases of dimpling. HEENT Head is normal with no injuries and hair normally distributed. Eyes: Equal sized pupils with intact EOMs. No erythema or conjunctivae injection. Ears are normal with no discharge noted. Easily visualized landmarks and bilateral TMs. Nasal mucosa is pink in color with turbinates that are normal. No case of septal deviation. Neck is supple with grade_benderSOAP NOTE 6 trachea in the midline. No case of cervical lymphadenopathy. No nodules or thyromegaly. Oral mucosa is pink in color with teeth that are in good repair. Cardiovascular S1 and S2 normal with regular pulses and pressure. No gallops, clicks or murmurs. Respiratory Chest wall is symmetrical with easy and regular respirations. Bilateral lungs that are clear to auscultation and percussion. Gastrointestinal Flat abdomen with no tenderness and bowel sounds heard in all quadrants. No case of hepatosplenomegaly. Breast Lump present with skin scaling and discoloration. Redness of skin is noted with nipple retraction. Slight nipple discharge noted. Dimpling is also noted and the left breast is swollen. Genitourinary Non-distended bladder with no case of CVA tenderness. External part of the genitalia shows coarse pubic hair with normal distribution. No lesions noted in the vulva. Examination shows pink vaginal walls that are well rugated with no abnormalities noted. Nulliparous and pink cervical wall. Cervix is firm upon bimanual examination. Uterus grade_benderSOAP NOTE 7 well positioned and all other factors within normal limits. Palpable ovaries. No tenderness Musculoskeletal ROM full and is visible in all extremities upon patient’s motion. Neurological Clear speech that has a good tone. Patient’s posture is erect with stable balance. Gait is normal. Psychiatric Patient pays attention and answers questions correctly. Well dressed and keeps a good eye contact. Lab Tests CBC- Pending results Mammogram- Positive for lump and shows an invasive component; pure ductal carcinoma Breast MRI- Lumps noted CT scan- Positive for ingrowing lumps. Hormone receptor testing- Pending results. Special Tests Biopsy- Pending results Diagnosis Breast cancer C50.919- This is the primary diagnosis due to the symptoms presented by grade_benderSOAP NOTE 8 the patient. Common symptoms such as skin dimpling, nipple retraction, discharge, lumps and masses in the breast are the main symptoms of this illness. In many cases, breast cancer is a genetic illness and the fact that the patient’s mother has breast cancer could support this diagnosis (Senkus et al., 2015). With this illness the patient may have nipple discharge that is not milk and the skin around the affected breast may have scaling or redness. In some cases the illness may spread to the lymph nodes if not treated early. The diagnosis is also supported by the mammogram results gotten from the tests. Fibroadenoma ICD 10- 60- This is due to the reported lump in the breast which is the main symptom of this illness. This is an illness difficult to distinguish from the primary diagnosis as the lump in this case is soft to touch and is felt to move easily under the skin. The lumps in this case are normally painless but may feel pain when the patient is near periods which is different from the breast cancer which is painful. Breast Cyst N60.09- This is due to the mentioned breast lump which is the main symptom of this illness. Other symptoms of this illness include a clear or yellow nipple discharge, a lump with and increased size with breast tenderness before periods which changes after periods. The breast may feel pain and have tenderness (Cardoso et al., 2016). In this illness, there is no case of skin scaling or dimpling hence ruling out as a primary diagnosis. Mastitis N61.0- This is an illness characterized by swelling of the breast as mentioned by the patient which makes it a differential diagnosis. Symptoms for mastitis include tenderness and warmth of the breast, thickened breast tissues and lumps similar to this case. A patient with this illness will have a general feeling of illness, pain and a burning grade_benderSOAP NOTE 9 sensation while breast feeding. In this illness, the patient may have fever which is not common in breast cancer. Plan/Therapeutics Treatment plan will involve a surgical removal of the breast lumps as the illness is still in the early stages. The patient will be subjected to chemotherapy that will help in eliminating the cancerous cells present. Mastectomy will also be included in the treatment plan. With this, it will be easy to improve the symptoms of the patient. The patient is advised not to apply too much pressure on the breast to avoid further injuries (Swain et al., 2015). Hormone therapy will also be considered in the plan depending on the risk factors of the patient. Referral will be to an oncologist for further implementation of the treatment plan. Evaluation of patient encounter Patient is a 29-year-old Hispanic female who comes to the clinic with breast pain, nipple pain and discharge. Additional complains reported are breast lumps felt by the patient. The set treatment plan will focus of chemotherapy that will be done after referral and further tests by an oncologists. I would not change the plan as it is evidence-based and has worked in previous cases. References Cardoso, F., van’t Veer, L. J., Bogaerts, J., Slaets, L., Viale, G., Delaloge, S., ... & Glas, A. M. (2016). 70-gene signature as an aid to treatment decisions in early-stage breast cancer. New England Journal of Medicine, 375(8), 717-729. Senkus, E., Kyriakides, S., Ohno, S., Penault-Llorca, F., Poortmans, P., Rutgers, E., ... & grade_benderSOAP NOTE 10