SOAP Note and Differential Diagnoses for iHuman Case "Carolyn Cross V3 Name: Carolyn Cross Date: 05/21/2018 Time: 1020 AM Age: 41 y /o Sex: F BMI (27.5) Height 5’ 3’’ Weight 155 pounds SUBJECTIVE CC: HPI: Ms. Cross is a healthy 41-year-old G2P2 Hispanic-American female who presents for a well-woman examination. She has no active medical complaints, but is concerned about her risk of breast cancer as both her mother (age 63) and maternal first cousin (age 44) have been recently diagnosed with intraductal breast cancer. She performs self-breast examines, no lumps or bumps or discharged noted by patient. She reports breast tenderness around her menstrual cycle. Medications: Current Medications: She takes vitamin E for fibro cystic breast disease, she had a mammogram 18 months ago. PMH: Denies any health problems past or present, she had a mammogram 18 months ago. Allergies: N/A Medication Intolerances: “None at this time” Chronic Illnesses/Major traumas. M. O. Denies any chronic illness or Major traumas at this time Other: Immunization: Immunizations are up to date. Family History She is concerned about her risk for breast cancer and does this fact increase her risk of breast cancer, her mother at 63 years old and first cousin 44 year old was recently diagnosed with breast cancer. Father has hyperlipidemia and HTN. Social History (SH): Pt has a glass of wine every night. Her supper diet is traditional Hispanic diet. She has two sons and a husband with no reported siblings. She gardens and does house work for exercise. This study source was downloaded by 100000825331278 from CourseHero.com on 05-07-2021 16:42:03 GMT -05:00 https://www.coursehero.com/file/33333910/SU-NSG6020-Week7ihuman-Oyi-Ldocx/ This study resource was shared via CourseHero.com ROS General Denies cough, night sweats. No recent weight again. Or weight loss. Completed 2018. Cardiovascular Patient denies chest pain, no murmurs, bruits, palpitations, orthopnea or edema Heart –when palpating for PMI (Point of Maxima/ Impact), the PMI is in the 5th intercostal space (ICS) at the mid-clavicular line (MCL)_ Skin The skin is warm and dry. No rash, bruising or cuts to skin and abnormal hair and nail growth. Blanching observed for Quincke’s test. Respiratory Denies “cough, hemoptysis, SOB, pneumonia, wheezing and an exposure to TB” Eyes Pt denies using glasses. Red reflex bilaterally Optic disks sharp Gastrointestinal Denies “N/V/D, constipation, Abdominal pain, hemorrhoid, eating disorder” Ears Normal appearing external structures; no deformities or edema. No discharge noted Normal-appearing external auditory canals. Tympanic membrane translucent, noninjected and pinkish-gray in color. No scarring, discharge or purulence noted. Normal landmarks. Normal mobility with insufflation. Genitourinary/Gynecological Normal extemal genitalia Parous introitus Normal vaginal mucosa • Cervical eversion (ectropion) without friability; samples collected for Pap smear No abnormal discharge Uterus firm, slightly irregular in contour per bimanual exam • Adnexa difficult to palpate, nontender Nose/Mouth/Throat “Denies hoarseness, sinus problems, nose bleeding” No discharge or polyps No edema or tenderness over the frontal or maxillary sinuses. Musculoskeletal No asymmetry or deformity of the back No tenderness or spasm of the paraspinal muscles No localized tenderness of the spinous processes or pelvic structures. Musculoskeletal - test Strength is 5/5 bilaterally (MRC scale; 0=complete paralysis; 5= normal power) Breast Normal, symmetrical breast contour No visible skin or nipple abnormalities No spontaneous or expressed nipple discharge or blood Irregular "lumpy bumpy" consistency throughout both breasts; no suspicious, discrete palpable lesions Slight, diffuse tenderness to exam reported Neurological Denies any neurological defect at this time. This study source was downloaded by 100000825331278 from CourseHero.com on 05-07-2021 16:42:03 GMT -05:00 https://www.coursehero.com/file/33333910/SU-NSG6020-Week7ihuman-Oyi-Ldocx/