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Soap Note: Mammogram Test

Home Free essays Health Soap Note: Mammogram Test

Patient’s initials:

Subjective Data:

The patient visited the hospital for a regular checkup. She seems healthy from the onset of things while one could not help but notice that she looked a bit heavy though nothing seemed alarming. According to her self-assessment, she exercises daily by walking five days a week to and from the train station. She also expressed her enthusiasm by stating that during the weekends she would spend most of her time gardening.

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Chief Complaint:

Although Carol claims to be healthy, her only worry is that she thinks and fears that she might have breast cancer. It is determined by the fact that the patient has complained of bumps in her breasts. The patient further complains about the unilateral increase in body weight

History of Present Illness:

The patient complained about rapid weight gain and had tried working out a bit to restrain the ungodly weight increase. Upon further inquiry, the patient also revealed that she had a couple of uncertain feelings towards the shape of her breasts. She has never been on a particular type of medicine even after experiencing the above symptoms. Though she had a change of diet, her unilateral weight is rapidly increasing. Upon using self-palpitation, she realized that her breasts were lumpy and needed a practitioners’ help in the shortest timeline.

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The mentioned patient does not have a record of hospitalization. Carol has never had a history of blood transfusion whatsoever and no instances of high blood pressure in her files. The patient was diagnosed with diabetes recently; luckily for her, she has no history of tuberculosis.

After the birth of her last-born son, the patient decided to have a bilateral tubal ligation (BTL) at the age of 35. BTL is a surgery which involves the blockage of the fallopian tubes hence preventing pregnancy.

The patient had two pregnancies followed by two deliveries that happened after 24 weeks. Hence, the recording was indicated as gravida2, para2 (G2 p2). The patient has not had significant medical issues, and it appears that there is nothing to worry about at the moment.

According to the patient’s gynecological history, she experiences frequent menstrual cycles which do not deviate in duration. In fact, she had her first menstrual cycle at the age of ten.

Significant History

The patient’s mother has diabetes type 2; recently she has been diagnosed with intraductal breast cancer. Her father is one who suffers from hypertension and hyperlipidemia which is quite unfortunate. The patient’s first cousin aged 44, unfortunately, was diagnosed with intraductal breast cancer.

Social History

Carol is a middle school learning specialist who has been married to one husband for 13 years. She is a mother of two sons, one is seven years-old while the other has a tender age of five. The patient has a good track record with no incidences of drug abuse. Carol is from a Hispanic-American background, doing well financially with no history of domestic violence.

Review of Symptoms

Integumentary: positive for symptoms that could indicate breast cancer; denies the possibility of a one hundred percent outcome.

HEENT: negative indication of thyroid infection and a possible indication of thyroid cancer.

Respiratory: negative symptoms of lymphatic inflammation.

Gastrointestinal: positive for being slightly obese; denies the possibility of an overweight patient that could indicate the likelihood of diabetes.

Musculoskeletal: negative results from painful ligaments, tendons, and bones.

Neurological: negative results that would indicate defects or abnormalities in the neural function.

Endocrine: negative for a malfunctioning endocrine system.

Hematologic: negative hematologic malignancy.

Psychologic: negative psychological disorders of the patient.

Objective Data

Visual Sings:

BP-134/74mmg, P-76bpm-regular, R-16bpm, WT-148,HT-5’.3’ ,BM-27.5,OBP-122/72mmHg

Physical Assessment Findings:

HEENT: Thyroid within normal limits with fervent consistency.

Lymph Nodes: lymphadenopathy evidence in the system.

Carotid: no plague evidence in the arteries. There is no evidence of sclerosis within the carotid arteries and jaguar vein. Hence, the patient has no sign of edema.

Lungs: breathing of the patient is healthy. The thorax movement and respiration pattern are standard. The chest cavity was cylindrical at the same time unilateral.

Heart: the heartbeat rate of the patient was 72, hence regular and rhythmic.

Abdomen: patient is mildly obese though it is important to note that there is the absence of hepatosplenomegaly. The liver and the spleen are in the right shape and size.

Genital/pelvic: the patient’s genitalia is normal. Normal vagina mucosa, which is good suffice to say there is no evidence of cervical eversion. Samples had to be collected for the pap smear test.

Neurologic: CN II-XII is intact, the patient has passed crania nerve examination. Deep tendon reflexes were 2T which were good, and the patient passed the exam.

Rectum: after conducting a colonoscopy, the patient’s large intestines were in their proper shape. There was no evidence of lumps in the entire region.

Extremities: upon checking the breasts, there were irregular consistencies in the breasts.

Assessment (3 priority diagnoses with 1CD-10 codes placed in order of priority)

Breast Cancer Assessment

C79.81. It is imperative that the patient should undergo a mammogram test to check whether she has breast cancer. Since cancer is one of the most significant concerns for the patient, it is paramount that the client undergoes a biopsy (Houssami & Miglioretti, 2016). This norm helps in maximizing the identity of cancer. Upon further assessment, acute pain related to the growth and formation of somatic nerve endings can be detected. One should also not forget the fact that edema is a result of ineffective tissue perfusion which could also lead to painful experiences for the patients (Burns, 2015).

Cervical Cancer Assessment

Z85.41. Since the patient is in a monogamous relationship, she is advised to have pap smear tests. The infamous HPV virus if not checked can be dominant for a sustained period if one is not careful (Keppler, 2016). This norm will be achieved by scraping a few cells from the cervix unable to look for abnormal growth. This test ensures that cervical cancer will be screened and identified early.

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Physiological assessment

F06.4. Another essential part of this diagnosis is that the patient needs to undergo a prognosis to prepare her for the worst possible outcomes.

Plan Care

For the pain the patient is experiencing, a single dose of analgesics will become administered. This medication will help ease the pain. One cannot refute that the patient has some inflammations on her breasts, hence a dose of anti-inflammatories will help reduce the swelling. If left untreated or controlled the patient might have a rather nasty experience with oedema.

As we all hope for the best, one cannot ignore the psychological trauma that the patient will experience if she finds herself beneath the oppressing power of cancer. Most patients suffer from shell shock after knowing they have cancer.

The patient will have to undergo counseling, as we wait for the test results. It is essential that the patient should come for advice every week should the odds of the results not favor her.

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