SOAP Note and Differential Diagnoses for Human Case.

SOAP Note and Differential Diagnoses for Human Case.

41 years

5′ 3″
155 pounds

Name: Carolyn Cross
Age: 41 years
Sex: F
Height: 5′ 3″
Weight: 155 pounds (BMI 27.5)

Temperature: 98.4 F (oral)
Pulse: 76 bpm – regular
Blood pressure: 134/74 mmHg 122/72 upon standing
Respiratory rate: 16 bpm
SpO2: 98% on room air

Carolyn Cross

Chief complaint:
Well-woman evaluation

SOAP Note and Differential Diagnoses for iHuman Case.

Use this week’s iHuman case titled “Carolyn Cross V2VE” and create a SOAP note with a treatment plan (located at the bottom of the SOAP note.

• Provide a subjective, objective, assessment, and plan (SOAP) note on this patient and your treatment plan using the SOAP note template provided. Remember to keep the patient’s identity private; use the minimal amount of information possible to get the idea across.
• Provide a reference for your treatment plan (in APA format). The reference may come from a journal, a book, etc.
• Cite all sources using APA format.
• Include three differential diagnoses and support your diagnoses with supporting literature.

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. Additional risk factors include menarche age 10.5; first pregnancy age 33; she breast fed each of her two infants for only four months each. The patient, reports a normal baseline mammogram at age 40, (report not available) and a history of fibrocystic breast disease. She is overweight (BMI 27.5) with a FH of hypertension, hyperlipidemia (father) and type 2 diabetes (mother).

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. She performs self-breast examines, no lumps or bumps or discharged noted by patient. She reports breast tenderness around her menstrual cycle. Denies any health problems past or present. Immunizations are up to date. She gardens and does house work for exercise. She reports later she takes vitamin E for fibro cystic breast disease, she had a mammogram 18 months ago. Father has hyperlipidemia and HTN and mother is a type 2 DM and just diagnosed at 63 with breast cancer. Pt has a glass of wine every night with supper her diet is traditional Hispanic diet. Both breast is irregular lump and bump bilateral with slight diffuse tenderness. She has two boys and a husband no reported siblings

SOAP Note and Differential Diagnoses for Human Case.

SOAP Note and Differential Diagnoses for Human Case.

labs

Her papsmear was normal