I-Human Patient “S” of SOAP
Carolyn Cross
Subjective
Chief Complaint
Patient is a 41-year-old adult female, Hispanic American presenting to the
... [Show More] clinic for a wellness
visit. Patient denies any medical complaints does express concern for recent family (mother and
first cousin) breast cancer diagnosis.
Past Medical History
Illnesses/Hospitalizations/Surgeries. Patient has a history of bilateral fibrocystic breast
changes. Patient denies any other major illnesses and hospitalizations. Patient has a
surgical history of a tubal ligation following last delivery at age 35 years. Patient had
normal spontaneous vaginal delivery x2. Patient breast fed both children for 4 months
each. Patient is premenopausal with menses regular since age 10.5 years.
Medications. Patient takes Vitamin E for fibrocystic breast changes. Patient also take
ibuprofen for occasional headaches.
Allergies. Patient denies any known drug allergies.
Preventative Health. Pap smears in past have been normal. Mammogram last year was
normal. Diet – patient states that she tries to eat a well-balanced diet. Last gynecological
exam was 3 years prior. Exercise – Patient walks to and from the train x5 days per week
and does gardening on the weekend. Immunizations are up to date with flu shot this past
year. Patient confirms that she does self-breast examination regularly.
Social History
Patient states she works full-time as a middle school learning specialist. Patient has been
married for ~13 years and states she has a good family life. Patient denies any tobacco or illicit
drug use. Patient states she has one glass of wine at dinner on most days. Patient states she tries
to eat a well-balanced diet but eats fast food once a week, eats Hispanic food, and loves desserts
eating cookies at night.
Family History
Father – history of HTN and hyperlipidemia
Mother – history of type 2 diabetes and recent breast cancer diagnosis
Sisters – none
Brothers – healthy; very physically active
1
st Cousin – breast cancer
Children – Two sons aged 6 and 8 years, respectively; healthy
Review of Systems
General/Constitutional
Denies. Fatigue, weakness, any new health changes, pain
Head, Eyes, Ears, Nose, Throat, Neck.
Denies. Headache/pain, eye pain, ear pain, throat pain, or neck pain. Cardiovascular.
Denies. Chest pain, shortness of breath, or difficulty breathing.
Respiratory.
Denies. Shortness of breath.
Gastrointestinal/Genitourinary.
Denies. Decreased appetite, abdominal pain, nausea, vomiting, diarrhea, dysuria, and
hematuria.
Musculoskeletal.
Denies. Neck pain, nuchal rigidity.
Integumentary.
Complains of. Multiple, bilateral lumps in breast that change, bilateral breast tenderness
upon exam.
Denies. Skin or nipple abnormalities, spontaneous or expressed nipple discharge or
blood, asymmetrical breast contour.
Neurological.
Complains of. Occasional headache resolved with OTC medications Denies.
Dizziness, blurred vision, weakness, and confusion.
Psychiatric.
Complains. Concern over recent family diagnosis of breast cancer.
Denies. Depression, anxiety, nervousness, excessive worry, diminished activities, feelings
of hopefulness.
Lymphatic.
Denies. Painful or swollen lymph nodes.
Allergic/Immunologic:
Denies. Environmental allergies, hives, hay fever. [Show Less]