SOAP Note Template

ID

First Name Betty

Last Name Burns

Gender Female

Age 48

CC

Lump on left breast for about one month.

HPI

History (including PMH, surgical, family, and social)

Other active problems: Hypertension – well controlled on Hydrochlorothiazide. Asthma – childhood diagnosis; occasional flares requiring oral steroids. Seasonal allergies – controlled. Mild fibrocystic disease. Obstetric History: Gravida 2, Para 2, Abortus 0. 1st child at age 36. 2nd child at age 38. Surgical History: 1. Appendectomy – > 20 years ago. 2. Tubal ligation after birth of second child. Hospitalizations: 1.  Births of children. 2.  Appendectomy. 3.  Tubal ligation. Preventive: Flu immunization recommended yearly. Weight loss recommended to 150 lbs. to bring her BMI to 24.2. Yearly mammograms. Seat belts – uses regularly. Texting while driving – never. Current on immunizations:1) up to date on Tdap. 2) up to date on influenza vaccination. 3) pneumovax administered at age 42 due to her asthma. Recommend shingles vaccination when turns 60. Family History: Mother – breast cancer age 55, alive and well. Father – medical history unknown. Sisters – none. Brothers – both alive and healthy. Grandparents – deceased unknown causes. Social History: Tobacco – none; secondhand smoke exposure minimal. Alcohol – social (once to twice monthly). Recreational drugs – none. Married – monogamous; two daughters, ages 8 and 10. Education – college graduate. Job – elementary-school principal. Travel – none recently. Pets – none. Home safety – no guns in household. Eating/Exercise:  eats most meals at  home, fast food only once per week, walks 1-2 times per week for exercise.

ROS (general, skin, HEENT, neck, breasts, resp, CV, GI, peripheral vascular, urinary, genital/LMP, MSK, psych, neuro, hematologic, endocrine)

General: No evidence of fever, chills, fatigue, malaise, night sweats, excessive or unexplained weight gain or loss. Skin/Breasts: No rashes, bruising, jaundice, pruritis, acne, sores, ulcers, changes in moles, hair loss or brittleness, nails. No pain from her breasts. Reports lump on left breast x 1 month. Found during self-breast exam last month. Discoloration near nipple on left breast. Lump on left breast thickened area over lump with indentations. Occasional bloody discharge in left breast cup of bra. Last mammogram 15 months ago and normal per patient. No movement with lump. Periods are regular every 26-28 days. HEENT/Neck: Denies vision changes, blurred vision; eye pain, discharge, itching, or redness. Denies ear pain, ear discharge, hearing difficulty, vertigo, nasal congestion, epistaxis, sinus pain or pressure, sore throat, swollen glands in neck, tooth pain. Cardiovascular: No complaints of chest pain/pressure, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, palpitations, ankle swelling. Resp: Denies shortness of breath, wheezing, cough/ sputum, hemoptysis, tightness in chest, pleuritic chest pain (pain with deep breath or cough). Abd/GI: No problems with appetite changes, dysphagia, nausea, vomiting, hematemesis, heartburn, abdominal pain, diarrhea, constipation, melena. GU: No menstrual irregularities, amenorrhea, dysmenorrhea, dyspareunia.  Denies dysuria, urinary frequency, nocturia, hematuria, incontinence, urgency, hesitancy, difficulty starting or stopping stream. MSK: No joint or muscle pains, joint stiffness and swelling, limitations in movement, functionality. Neuro: No problems with headaches, syncope, presyncope, dizziness, weakness, paralysis, numbness/tingling, or balance. Allergic/Immunologic: Denies food allergies, hives, or rashes. Lymphatic/Endocrine: Denies polyuria, polydipsia, polyphagia, tremor, heat or cold intolerance, hot flashes. Hematologic: Denies excess bruising or bleeding, swollen glands/lymphadenopathy. Psychological: No problems with mood changes, feeling depressed, manic behaviors, auditory or visual hallucinations, anxiety, insomnia, suicidal or homicidal ideations.

Allergies

Seasonal hay fever. NKDA. NKFA.

Current Medications

Fluticasone (Flonase) – one spray each nostril Q AM as needed for seasonal allergies. Fluticasone/salmeterol 250/50  – one puff BID for asthma. Hydrochlorothiazide (HCTZ) – 25 mg PO daily for hypertension.

Objective

Vital Signs:

HR 80 RRR

BP 128/80 mmHg – supine/sitting. 126/72 mmHg – upon standing.

Pulse 80 RRR

RR 16 unlabored

Pain 0

Height 5’ 6”

Weight 165 lbs. (75kg)

BMI 26.26

Temp 98.6 oral

Pulse Ox 99% room air

Physical exam (general, HEENT, neck/lymph, breasts, chest/respiratory, CV, GI/abdomen, GU/rectal, back, MSK, skin, neuro, psych)

Weight:  165.0 pounds. Skin/Breasts: Atraumatic, good skin turgor, skin, and scalp normal, no evidence of suspicious pigmented lesions. Breast exam consistent with known mild fibrocystic disease, left breast with subtle skin dimpling (peau d’orange appearance). Normal symmetrical breast contour bilat. No overt inflammatory signs. No previous incisions or trauma. Left breast and axilla: subtle skin dimpling (peau d’orange appearance), firm fixed, 3 cm mass palpated at the 9 o’clock position. No other suspicious mass lesions; smaller palpable nodules consistent with prior exams and consistent with history of fibrocystic disease. Expressible bloody nipple discharge. Solitary, nontender, mobile, 2 cm left axillary lymph node. Right breast small palpable nodules consistent with prior exams and known fibrocystic disease. No axillary adenopathy. No expressible nipple discharge. HEENT: Eyes: Sclera and conjunctiva normal. Pupils and irises size symmetrical and shows normal reaction to light and accommodation bilaterally. Ears: no external scars or lesions. Otoscopic exam normal with only minimal wax, no masses or foreign bodies, good light reflex bilaterally. Nose: External without abnormality. Normal nasal mucosa, septum, turbinate’s. Mouth: Good dental hygiene. Neck supple, no adenopathy, trachea midline, no carotid bruits, thyroid size 25 gm, no masses or tenderness. Cardiovascular: No JVD. No thrills, heaves, or lifts. PMI normal size and location.  Heart RRR Normal S1 and S2, no murmurs appreciated. No carotid bruits, abdominal aorta normal size no bruits, pedal pulses present and symmetrical, no evidence of peripheral edema or varicosities. Respiratory: Normal chest shape, normal respiratory movement, no tenderness, and percussion normal. Auscultation found normal breath sounds throughout without wheezing, rales or ronchi. Abdomen/GI: Flat contour. Scars consistent with prior surgical history. Normal bowel sounds present. Soft to palpation without tenderness all 4 quadrants.  Liver edge felt below the coastal margin, span normal to percussion. Spleen normal size. No masses or organomegaly. GU: Normal genitalia, no evidence of infection. Normal ovaries to manual palpation. Pap smear done. MSK: Normal ROM and muscle tone throughout. Muscle strength and flexibility throughout axial and appendicular skeleton normal. Motor 5/5 all extremities. Neurological: A & O x 4, good attention, memory, normal gait, CN 2-12 intact, reflexes 4/4 throughout. Normal cerebellar exam with finger to nose (FTN), rapid alternating movements (RAM), heal to shin (HTS) bilaterally. Allergic/Immunologic: No worrisome preauricular, posterior auricular, anterior cervical, posterior cervical, submandibular, supraclavicular lymph nodes. Lymphatic/Endocrine: Thyroid normal to palpation, 25 gm, no masses or tenderness. Hematologic: Normal capillary refill. No evidence of anemia.

Problem List:

  • Breast mass/lump, neoplastic
  • Invasive ductal carcinoma, left breast ER/PR negative, HER2 positive
  • Evidence of metastasis: 2 out of 2 left axillary lymph nodes positive for metastatic spread

 

Differential diagnoses:

Differential Diagnoses How Was This Diagnosis Ruled Out?
Breast hamartoma
Fibroadenoma
Breast lipoma

Include the following:

  • Medications to be prescribed (drug-dose directions)
  • Instructions to continue, discontinue, or start medications, including changes to routine medications.
  • Diagnostic tests in the proper order and reason for the order (e.g., CT abdomen and pelvis with and without contrast, Dx, LLQ abdominal pain)
  • Labs, including appropriate serum panels (e.g., BMP, CBC with diff., TSH, T4, UA, C&S)
  • Patient education pertinent to health condition
  • Follow-up plan
  • Referrals
Plan Rationale and/or results
Breast Cancer Susceptibility Genetic Test (BRCA1 and BRCA2). No mutation detected.
Diagnostic mammogram. Left breast BI-RADS 5, (3 cm irregular shaped mass in upper outer quadrant worrisome for malignancy). Right breast BI-RADS 1, normal.
Left breast biopsy with lymph node biopsy. Invasive ductal carcinoma with nuclear pleomorphism. Mitotic counts: score 2. Estrogen receptor negative. Progesterone receptor negative. HER2 receptor positive.
Breast ultrasound. Left breast solitary mass measuring 3 cm X 3.2 cm X 3.0 cm at 9 o’clock upper outer quadrant. Some skin thickening overlying the mass was also noted. In the left axilla 2.0 cm X 1.8 cm X 2.0 cm lymph node was identified. Suspicious for malignancy.
Surgical referral for modified radical left mastectomy and axillary dissection/removal of suspicious lymph nodes.
Radiation referral for therapy.
HER2 antagonist therapy (trastuzumab)
Oncology referral to discuss treatment options.
Referral for education, counseling, supported decision making and support groups. Life long cancer surveillance.
Lab to check lipid panel and BMP.

NRP/563: Management Of Women’s Health Issues

Wk 3 – Signature Assignment: iHuman Patient Betty Burns Reflection

  1. See attached SOAP note for Betty Burns.
  2. Write a 500-word summary regarding your patient encounter with Betty Burns.
  3. Include the following in your summary:
  • Explain how you arrived at your differential diagnoses.
  • Explain the steps you used to determine the final diagnosis.
  • Give examples of how you can integrate cultural preferences, values, health beliefs, and behaviors into the treatment plan using Watson’s theory.
  • Describe the appropriate management (e.g. health maintenance, diagnostics, medications/treatment) and support with evidence.)
  • Critique your overall case evaluation, highlighting takeaways to improve your clinical skills now that the diagnosis has been revealed.
  1. Cite a minimum of 3 peer-reviewed journal references within the last 5 years supporting your responses according to 7th edition APA guidelines.
  2. Course Textbooks:
  • Schuiling, K. D., Likis, F. E. (2017). Women’s gynecologic health (3rd ed.). Jones & Bartlett Learning.
  • Dunphy, L. (2019). Primary care: The art and science of advanced practice nursing (5th ed.). F.A. Davis.

Management Of Women’s Health Issues Week 3 – Signature Assignment: iHuman Patient Betty Burns Reflection

Student’s Name

Institution

Course Code, Course Name
Instructor’s Name

Date

Explain How You Arrived At Your Differential Diagnoses

Diseases are characterized by patterns of symptoms reported by patients, the signs obtained during physical exam, and the results obtained from diagnostic tests. According to Dunphy (2019), determining the differential diagnoses is a process of distinguishing between diseases which present with the same symptoms. In Betty Burns’ iHuman case study, I arrived at   the differential diagnosis   using a systematic approach through the following steps; generating a list of Betty Burn’s medical issues through history taking, a physical exam, and evaluating  the  findings of the laboratory tests. Burns’ chief complaint was a lump on her left breast for about one month. The most common problems which present with this symptom among women aged 40 years or older are; fibroadenomas, breast lipoma, breast hamartoma, and breast adenocarcinoma. Using a local anatomic differential diagnosis framework and applying to it the pertinent positives and negatives resulted in the following differentials;

  • Fibroadenoma-presents as a painless, benign and firm lesion
  • Fibrocystic Breast Disease: it usually presents with changes in breast tissue such as lobular hyperplasia and cysts that are smooth and movable (Schuiling & Likis, 2017).
  • For Betty Burns, the physical exam was also consistent with mild fibrocystic disease.
  • Breast Cancer-Betty Burns’ breast biopsy findings was significant for an invasive ductal carcinoma with nuclear pleomorphism which is indicative of breast cancer.

Steps Used To Determine the Final Diagnosis

  • To determine the final diagnosis, I identified the disease that accounted for all of Betty Burn’s problems from the initial list of differential diagnoses and was supported by the diagnostic test findings. The most appropriate diagnosis that met this criterion was breast mass/lump, neoplastic. Betty Burns was 48 years old and had a family history of breast cancer (mother). The risk of breast cancer increases in women aged 40 years and older (Schuiling & Likis, 2017). . She reported discoloration near the left breast nipple, an immobile lump on the left breast with thickening and indentations over the area with the lump. She also reported occasional bloody discharge in the cup of bra of the left breast. The physical exam findings were consistent with dimpling of the skin of the left breast, a fixed and firm mass (3cm) palpated at the 9 o’clock position, and bloody nipple discharge. The diagnostic breast biopsy was positive for an invasive ductal carcinoma, HER2 positive with evidence for metastasis (2 out of 2 left axillary lymph nodes positive for metastatic spread).

How To Integrate Cultural Preferences, Values, Health Beliefs, and Behaviors Into the Treatment Plan Using Watson’s Theory

Watson bases her theory of caring on seven major assumptions starting with the notion that caring can only happen at an interpersonal level between nurses and patients. Oher assumptions posit that caring   leads to growth of the patient and family, patient satisfaction, needs acceptance, is the core of nursing, and creates an environment where individuals make wide decisions (Pajnkihar, Štiglic & Vrbnjak, 2017). Basing on the aforementioned assumptions, she mentions  10 Carative factors  that nurses can implement in practice to; instill hope, develop trust, develop values, incorporate science to address  issues, support  a positive mental,  physical, social, and spiritual environment, continuous learning, and  help with physical needs (Pajnkihar, Štiglic & Vrbnjak, 2017). Applying this theory to the care of Betty Burns, I will develop a helping-trusting relationship and allow her to share both her positive and negative feelings, being authentic to, engage Betty Burn in genuine teaching-learning experience about her health status, and try to address her spiritual and physical needs by being open to discussions and matters spirituality.

Appropriate Management (Health Maintenance, Diagnostics, Medications/Treatment)

  • Non-pharmacological treatment: refer for modified radical left mastectomy and axillary dissection/removal of suspicious lymph nodes.
  • Pharmacological treatment: refer for radiation or/and chemotherapy (HER2 antagonist therapy (trastuzumab) (Schuiling & Likis, 2017).
  • Patient Education: breast cancer and gynecological follow up in six months, lifelong cancer surveillance screening (clinical breast exam every 6-12 months), MRI/mammogram every 6-12 months.
  • Diagnostics:
    • Genetic Testing (BRCA)-No mutation detected.
    • Left breast biopsy with lymph node biopsy- Invasive ductal carcinoma with nuclear pleomorphism. Mitotic counts: score 2. Estrogen receptor negative. Progesterone receptor negative. HER2 receptor positive.
    • CT of abdomen and chest
    • Diagnostic mammogram- Left breast BI-RADS 5, (3 cm irregular shaped mass in upper outer quadrant worrisome for malignancy). Right breast BI-RADS 1, normal.
    • Breast ultrasound-Left breast solitary mass measuring 3 cm X 3.2 cm X 3.0 cm at 9 o’clock upper outer quadrant. Some skin thickening overlying the mass was also noted. In the left axilla 2.0 cm X 1.8 cm X 2.0 cm lymph node was identified, suspicious for malignancy.
    • BMP
    • Lipid Panel
    • Referral to an oncologist for further evaluation and management

Overall Case Evaluation and Takeaways

In my next assessments, I will be keener to conduct a more focused history taking and physical exam based on a patient’s presenting complaint. A focused history using focused questions and a focused physical exam will provide more comprehensive and direct clues of a patient’s most probable diagnosis. When compared to past assessments, I must admit that my history taking and physical exam techniques have tremendously improved. Besides, I can effortlessly incorporate pathophysiology knowledge that I have obtained in class in clinical and diagnostic reasoning to determine the appropriate tests to order and make appropriate diagnoses.

References

Dunphy, L. (2019). Primary care: The art and science of advanced practice nursing (5th ed.). F.A. Davis.

Pajnkihar, M., Štiglic, G., & Vrbnjak, D. (2017). The concept of Watson’s carative factors in nursing and their (dis)harmony with patient satisfaction. PeerJ5, e2940. https://doi.org/10.7717/peerj.2940

Schuiling, K. D., Likis, F. E. (2017). Women’s gynecologic health (3rd ed.). Jones & Bartlett Learning.

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