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
... [Show More] 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
Nose/Mouth/Throat
Denies having any lesions, masses and tenderness. Also denies difficulty of hearing, vertigo and throat pain.
Musculoskeletal
Denies weakness, stiffness and joint pain
Breast
Denies rashes, bruising, sores, lumps, dryness and color changes.
Neurological
Denies numbness and tingling, denies having vision or hearing problems, tremors, and gait instability. [Show Less]