Assignment: Preventative Health and Assessing, Diagnosing, and Treating Special Populations
Use the Focused SOAP Note Template to address the following:
Please complete the SOAP note with Diagnostic test/labs, Assessment (Primary Diagnosis and Differential diagnosis), Plan and reflection.
FOCUS SOAP Note
Patient Initials: ML Age: 28 Gender: Female
CC (chief complaint):â€I have milky discharge from my right nipple.
HPI: ):Marcia is a 28 year old Hispanic female who comes in with a complaint of nipple drainage on her right breast. She says that the discharge started about three months ago and it appears milky. She says that she has also felt tired, experienced occasional headaches and has been constipated lately.She also reports breakout of Acne on her upper back and forehead. Her periods have been very light. She is worried that she â€œmight have cancerâ€.Her symptoms are not associated with breast tenderness or pain, no fever and no visual changes.
Location: Bilateral breast.
Onset: 3 months ago
Exacerbating/ relieving factors:
Radiates: upper back
1.Lutera (Oral contraceptive pills)
2.Sertraline 50 mg PO OD for depression.
Allergies: No known drug allergies
1.Depression-well controlled with medication
Soc & Substance Hx: Right-handed, married and has 1 children who are living with them. Social history is negative for tobacco, alcohol, and recreational drugs. She practices healthy eating habits and uses a seatbelt while in the vehicle.
Fam Hx: Her parents are both alive. Father has a Heart disorder. Mother has Hypothyroidism.
Mental Hx: H/o depression well-controlled with medication, no suicidal, self-harm, or homicidal thoughts.
Violence Hx: Denies history of domestic violence.
REVIEW OF SYSTEM:
CONSTITUTIONAL: Patient denies chills, fever, weight loss, diminished appetite, unusual thirsty, or unexpected generalized weakness.
NEUROLOGIC: Denies headache, tremors, seizures or gait imbalance, denies tics or numbness in lower extremities, no dizziness, no visual disturbances or speech problems.
PSYCHIATRIC:Reports h/o depression weâ€ll controlled with medication. Patient denies felling of sadness or diminished appetite, denies anxiety, denies exposure to violence, or sleeping problems. No suicidal ideation.
HEENT: Denies odontalgia, difficulty swallowing, sore throat, hoarseness, ear pain/pruritus or hearing loss.
RESPIRATORY: Denies shortness of breath, cough or chest pain.
CARDIOVASCULAR: No chest pain, palpitations or intermittent claudication, no recent skin rashes, petechiae or unexpected bleeding.
GASTROINTESTINAL: Denies heartburn or regurgitation, no diarrhea, no other kind of abdominal discomfort including any kind of pain, no colicky-like painful sensation after eating grassy food, no history of abdominal surgery, denies constipation or rectal bleeding.
GENITOURINARY: Bowel and bladder continent, denies dysuria, polyuria, cloudy or foul urine recently, no evident blood in urine, denies history of ulcers, vesicles, genital discharge/pain, denies sexual dysfunction.Reports shorter menstrual cycle.
SKIN:Reports worsening acne breakout in her upper back and forehead since starting birth control 6 months ago.
MUSCULOSKELETAL: Denies muscle or joint pain, no muscle weakness or spasms.
CONSTITUTIONAL: Blood pressure is 128/77; heart rate is 81; respiration rate is 16; O2 saturation is 98% on room air; and temperature is 98, weight 152 pounds, height 5’6”, BMI 24.5 NEUROLOGIC: AAOx4, no central or peripheral focal neurological deficit, gross sensation, muscle tone and grip strength intact, reflexes intact, no gait disturbances, Romberg test negative, negative Kernig’s and Brudzinski’s signs.Reports occasional headaches.
PSYCHIATRIC: Clear speech, normal rate and answers to questions appropriately. Normal and logical rate of thoughts. Keeps eye contact.
HEENT: EOMs intact, PERRLA, no redness or discharge noted in the ear canal, pearly and non- bulging tympanic membrane bilaterally, no jugular veins distention, no neck mass or enlarged lymph nodes. No white/yellow plaques or ulcers noted on palate, uvula or tonsils, no erythema noted on oropharynx. Normal results obtained after performing Rinne and Weber tests. CARDIOVASCULAR: S1 and S2 RRR, no murmurs, no collateral circulation, no peripheral edema, carotid, apical, radial femoral and pedal pulses present and strong, no carotid murmur bilaterally. RESPIRATORY: No cyanosis, rhonchi or crackles noted, vesicular murmur present bilaterally. GASTROINTESTINAL: Oral cavity with no lesions suggestive of malignancy, wet oral mucosa, abdomen soft, non-tender, non-distended, no hernias, no organomegaly, bowel sounds present in all four quadrants.
GENITOURINARY: States milky-like nipple discharge for the last 3 months. This is first time episode. Symptoms aren’t associated with breast tenderness or pain, no fever, no AMS or visual changes, no dizziness but reports headache, light menstrual period. Upon pelvic PE no vulvar erythema is evident, no vesicles or ulcers, speculum exam shows no ulcers or vesicles, no excoriations. Pregnancy test negative.
MUSCULOSKELETAL: Joints without swelling, increased temperature or redness.
INTEGUMENTARY: Intact skin, warm, pink, no alopecia or desquamative lesions on lower
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