Betty Burns diagnosis is based on a two part evaluation and the first part has a SOAP Note that integrates, the diagnosis, history, tests and the recommended medication plan.
Name Betty 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 NRP/563: Management Of Women’s Health Issues – Betty Burns iHuman Reflection.
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 NRP/563: Management Of Women’s Health Issues – Betty Burns iHuman Reflection.
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 NRP/563:
Assessment
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 |
Plan
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 NRP/563: Management Of Women’s Health Issues – Betty Burns iHuman Reflection. | |
| Referral for education, counseling, supported decision making and support groups. Life long cancer surveillance. | |
| Lab to check lipid panel and BMP. |
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