week 4 soap

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 years old, African American woman that came to the office today because she noted something hard in her left breast five days ago when she was taking a shower, she is afraid to touch that part again so she does not know if the mass is still there. She denies pain, or skin breast changes, no nipple discharge has been noted. She denies fever or chills. Last period was on 02/28/2020. She had her PAP smear and mammogram every year. The mammogram always reports density in both breast and PAP smear has been normal. Patient is very concerned because she has a strong family history of breast cancer. Patient do not use any form of contraception.

Medications:

Omeprazole in the morning for gastric reflux. Diclofenac three times a day during her period for pain. Emgality subcutaneous injection once a month for migraine headaches. Vitamin C daily to support immunity. Women multivitamin daily. Calcium daily as a supplement.

PMH (include-immunization status including Gardisil, GTPLA).

Current or past illnesses: Migraine (20 years ago), Dysmenorrhea, GERD (5 years ago).

Immunizations: All vaccines updated except Gardasil.

Allergies:  Sulfas.

Medication Intolerances: None.

Chronic Illnesses/Major traumas: None.

Hospitalizations/Surgeries (include delivery of pregnancies here)

C-Section (1999). Pregnancy History: G2T1P0A1L1.

Family History

Mother: Alive 69 years. Parkinson’s Disease. Father: Decease, Pancreatic cancer. Aunt, maternal side: Breast Cancer (survivor), diagnosed when she was 52 years old. Children: One son, alive and healthy.

Social History

Patient is married, lives with her husband and a son in a house. Works as a secretary in a durable medical equipment company. Education level bachelor. Sexually active with her husband only. Drinks coffee 3 or 4 cups per day. Drinks 2 glasses of wine once or twice a month. Do not use recreational drugs. Do not use e-cigarettes. Drives and use the safety belt. Uses sunscreen.

ROS (if you are seeing a patient for an Episodic OV – you may alter the ROS accordingly)

General

Refers weight gain about 15 pound in the last year due to lack of exercises, refers feeling tired in days previous at her period. No fever or chills.

Cardiovascular

Denies chest pain, or discomfort. Denies palpitations, dyspnea, or orthopnea. 

Skin: Denies presences of moles, rash, or itching.

Respiratory: Denies dyspnea, cough, hemoptysis, or pleuritic pains.

Eyes

Use corrective lenses. Denies problems or changes in his vision; denies double or blurred vision.

Gastrointestinal

Denies hemorrhoids, constipation, or diarrhea. Positive for gastric reflux sometimes in the morning. No variation in bowel habits. Denies nausea, vomiting.

Ears

Denies difficulty or changes in his hearing. Denies tinnitus, or discharges.

Genitourinary/Gynecological

Menarche 12 years old. LMP: 02/28/2020 lasted 4 days, flow as usual. Last PAP November 2019, normal. No history of STDs. Do not use any contraceptive method. Pregnancy History: G2T1P0A1L1, by C-section. Positive for bloating and pelvic pain before her period. Denies dysuria, frequency or urgency. No blood in urine, no urinary urgency. No vaginal discharge.

Nose/Mouth/Throat

Denies nosebleeds, nasal obstruction. No Bleeding gums, teeth or mouth pain, no lesion in mouth or tongue, no dry mouth, or excessive salivation.

Musculoskeletal

Denies joint stiffness, limitation of movement, no history of musculoskeletal or disk diseases.

Breast

Refers breast tenderness before her period. Denies alteration of nipples, or discharge. Positive for a mass in the left breast. Last mammogram on December 2019, normal.

Neurological

Positive for headaches before and after her period. Denies syncope or seizure. No dizziness or vertigo.

Heme/Lymph/Endo

Denies bruising or bleeding. No history of anemia, blood transfusions. Denies exposure to toxic agents or radiation. No HIV history.

Psychiatric

Denies sadness, or anxiety. No sleeping problems.

OBJECTIVE - (if you are seeing a patient for an Episodic OV – PE should relate to the CC)

Weight: 170 lb.        BMI: 29.2

Temp: 98.1

BP: 105/56

Height: 5’4’’

Pulse: 95

Resp: 18

General Appearance: Patient is alert and oriented x 4. Well-developed and nourished. She speaks clearly and appropriate. Good personal hygiene.

Skin: Intact, clean, and moist. Well hydrated, no rashes or lesions observed.

HEENT: Normocephalic, symmetric. Eyes: Sclera white, conjunctiva pink. PERRLA. Ears: Bilateral canals patent. No exudate. Nose: External aspect is normal. Lips and oral cavity pink and moist. Thyroid has a normal size, no nodules or masses noted.

Cardiovascular: S1, S2. Regular rate and rhythm, no murmurs, no gallops. No thrill or palpable murmurs on palpation. All peripheral pulses are present. No edema.

Respiratory: Lungs clear to auscultation bilaterally, normal respiratory effort. No rales, no rhonchi, no wheezes upon auscultation.

Gastrointestinal: Soft, no tenderness, no masses, Bowel sounds presents in all four quadrants. No ascites. No splenomegaly, no hepatomegaly. No rebound, no guarding.

Breast Breasts symmetric: Left breast mass measuring 2.5cm x 2.5cm lesion, round, superficial located in the upper outer quadrant, at 10 o’clock position, regular borders, moves freely. No discharge, no dimpling, wrinkling or discoloration of the skin; no skin retraction, no lymphadenopathy in left axilla. Right breast with no masses or skin abnormalities. No palpable adenopathy in the right axilla.

Genitourinary: No CVA tenderness. Genitalia: External genitalia with pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions or masses noted. Cervix with scant, clear discharge. Bimanual examination: Mobile cervix, not painful. No adnexal masses or tenderness. Vaginal walls are smooth and pink; no lesions noted. Ovaries are non-palpable.

Musculoskeletal: Normal gait and ROM. No joints and muscle tenderness, no warmth, no erythema or inflammation.

Neurological: Speech normal, no neurological focalizations, no sensory-perceptions disorders. No altered mental status.

Psychiatric: Alert and oriented times 4. Patient is anxious, no signs or symptoms of depression, no suicidal ideas, maintains eye contact.

Lab Tests (list the results if you have them)

Diagnostic mammogram.

Breast Ultrasound.

Special Tests (done or ordered during the OV)

None

 Diagnosis – include the appropriate ICD – 10 Code for each diagnosis used

Primary Diagnosis:

1-Fibroadenoma (D24.2). Fibroadenomas typically smooth, rounded, mobile, painless masses; they may be mistaken for cancer. They usually develop in women during their reproductive years and may decrease in size over time (Kosir, 2019).

Differential Diagnoses:

1-Breast cancer (C50.412): More commonly presents as a breast lump with or without nipple inversion, discharge, or tenderness. Many breast cancers are noticed as a mass by the patient or during routine physical exam or mammography study. Less frequently, the presenting symptom is breast pain or enlargement or an unremarkable thickening in the breast (Kosir, 2019).

2-Unspecified lump in breast (N63): After lung cancer as the leading cause of cancer deaths in women, breast cancer is the most usual female malignancy, accounting for 26% of malignancies in women. The most common symptom of breast cancer is a new lump. A painless, solid mass that has irregular borders is more likely to be cancer, but breast cancers can be soft, or round. They can even be painful (Breast Cancer Signs and Symptoms, n.d.).

3-Breast cyst (N60.09). Breast cyst is common in women before menopause, between 35 and 50 years old, but they can be found in women of any age. They can also occur in postmenopausal women taking hormone treatment (Breast Cyst, 2018).

Plan/Therapeutics (explain fully)

Plan: 

Pharmacologic: Continue taking your medications as before. Take Diclofenac with food to minimize upset stomach.

Non-pharmacological.

1. Bilateral diagnostic mammogram and breast ultrasound.

2. Follow up visit in one week for results.

Referrals:

Refer all suspicious breast lumps and abnormal mammograms to surgeon for management.

Education:

Patient was educated about her clinical condition and concern; she says she understood the information well and did not have questions to ask.

Annual mammogram screening is the most effective tool to reduce breast cancer mortality.

Educated patient that if she does not use a contraceptive method, she can get pregnant and at her age a pregnancy can be complicated for her and the baby. I offered some contraceptive methods, but she refused explaining that she has been without contraception for about 15 years and she has not become pregnant.

The best time to examine your breast is about seven to eight days after your period. If you find any suspicious masses, report them immediately to your health care professional for testing. Tumors found during your monthly self-exam are usually in an early stage. You have a better outcome and a higher long-term survival in these cases if cancer is found. Most lumps are not cancerous.

Performing regular breast self-exams will allow you to be familiar with your body and prepared you when a change in your usual breast tissue is found.

Moderate physical activity performed 5 times a week as well as a healthy diet help maintain aa adequate weight and reduce cardiovascular events. Increase the amount of fruits and vegetables and reduce fast food meals.

References

Breast Cancer Signs and Symptoms (n.d.). Retrieved from https://www.cancer.org/cancer/breast- cancer/about/breast-cancer-signs-and-symptoms.html

Breast cysts. (2018, November 6). Retrieved from https://www.mayoclinic.org/diseases-conditions/breast- cysts/symptoms-causes/syc-20370284

Kosir, M. A. (2019, July). Breast Cancer - Gynecology and Obstetrics. Retrieved from https://www.merckmanuals.com/professional/gynecology-and-obstetrics/breast-disorders/breast-cancer?querybreast cancer

Kosir, M. A. (2019, July). Breast Masses (Breast Lumps) - Gynecology and Obstetrics. Retrieved from https://www.merckmanuals.com/professional/gynecology-and-obstetrics/breast-disorders/breast-masses-breast-lumps?queryfibroadenoma

 Evaluation of patient encounter:

I agreed with my preceptor that this patient has Fibroadenoma, the lesion in her breast felt smooth and mobile with regular borders. It is also localized superficial and not deep in the tissue. This lesion can change with the menstrual cycle. The patient was very anxious because of her family history of breast cancer but when we explained the characteristics of the lesions of breast cancer, she left less worried and her anxiety improved. My preceptor explained that a diagnostic mammogram is best in this case due to her familial history of breast cancer and because the anterior mammogram reported breast density.