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NSG 6020 SOAP NOTE iHuman Week 7 | iHuman Week 7 SOAP NOTE

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NSG 6020 SOAP NOTE iHuman Week 7 iHuman Week 7 SOAP NOTE SOAP NOTE iHuman Week 7 SOAP NOTE Name: Mrs. C Date: May 18, 2018 Time: 4PM Age: 41 years old Sex: Female SUBJECTIVE CC: “I�... �m just here for a wellness check-up. I just want to know my risks of having breast cancer since my mother and my cousin was recently diagnosed with one.” HPI: Seen and examined Mrs. C, a 41-year old healthy Hispanic – American Female presented in the clinic for a well-woman examination. She denies having any active medical condition but voices out concerns regarding breast cancer risk as her mother and maternal cousin was just recently diagnosed with it. Patient reports having a history of fibrocystic heart disease. Denies any pain or discomfort. Last mammogram check was 18 months ago and was normal. Patient also states that she does regular self-breast examination and denies finding any lumps or having discharges. Medications: Vitamin E daily for Fibrocystic changes Aspirin or Acetaminophen as needed for headaches PMH Allergies: No known Allergies Medication Intolerances: None Chronic Illnesses/Major traumas: Fibrocystic changes Hospitalizations/Surgeries OB/GYN: G2P2 Tubal ligation: (35 years of age on second pregnancy) Family History Mother – Breast Cancer (Dx 2 months ago) Father – Hypertension and Hyperlipidemia Patient has 2 sons both healthy Patient has 2 brothers both healthy Maternal cousin – Breast Cancer (recently diagnosed) Indicates Patient Living Male Living Female Social History Patient is a medical school specialist, lives with her husband and two sons, denies smoking or chewing tobacco, denies any use of illicit drugs but reports glass of wine intake every night. Denies being intoxicated. Patient is functionally independent in all aspects of responsibilities. ROS General 41 years old, Hispanic female, alert and oriented x 4, able to make needs known and alert during interview Cardiovascular Denies experiencing chest pains, palpitations and lightheadedness. Skin Denies delayed healing or bruising. Skin color is appropriate for ethnicity. Denies any changes in moles. Respiratory Denies wheezing, shortness of breath or history of TB. Eyes Denies the need for corrective lenses as well as having exudates and discharges from eyes. Gastrointestinal Denies abdominal pain, nausea and vomiting, ulcers, black tarry stools. Denies any problem moving bowels. Regular and reports to go several times a day. Ears Denies Ear pain, hearing loss, ringing in ears, and any discharges. Genitourinary/Gynecological Denies any frequency, burning, nocturia, urgency, dysuria, hematuria or discharges. Last Pap smear & mammogram – 18 months ago both normal Denies menstrual complaints. Last cycle 2 weeks ago and denies vaginal discharges. G2P2 - - - - - - - Continued [Show More]

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