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Annotated Soap Note - Assignment Example

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Three months have passed since I saw a doctor after the lumpectomy surgery I underwent. I want to get married but I need to verify my present status”.
HPI: 30 y/o African American woman presents to the clinic for…
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Annotated Soap Note
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Annotated Soap Note

The pain does not extend to other areas and the mass is located close to the nipple and feels hard when touched. The lump emerged about three weeks ago. The patients report no change in the size of the breast and there is no discharge.
Pertinent medical: immunizations up to date (last TD Jan 2015). She has undergone post mastectomy radiation therapy six months, 20mg/day tamoxifen, and 600mg ibuferon. The patient denies ever using hormonal drugs.
Family history: Her mother passed away due to breast cancer at the age of 65 years. The father living (70-year-old) has history of hypertension and DM. has two siblings (brother 35 years old and sister 37 year old) both in good health.
Social history: She admits smoking three to five cigarettes a day but denies using hard drugs and alcohol. The patient is single and has no children. She is an active dancer and participates in swimming. Her current diet is low calorie with a lot of fruits and vegetables.
General: Presents in a normal state of “good” weight and health. No recent weight loss or gain. No presence of rash around the nipple of the left breast. There is pain on the lump when pressed. No lumps on the armpit.
HEENT: no problem with hearing or vision. No headaches or dizziness. Normal nasal diameters, and no running nose or congestion. There is no evidence of removable or permanent dental. Last dental assessment conducted on January 2015.
The lump is smooth, rubbery and moves with ease within the breast tissue. A fine needle aspiration was conducted to obtain a tissue for testing. There is no bleeding or discharge from the nipple and neither is there any change in color.
The diagnosis is based on three assessments imaging, cytopathological and clinical. The three assessments aim to reduce the effect of any technique of diagnosis being less than 100% specific and sensitive to diagnose or eliminate breast cancer. The clinical assessment aim to ... Read More
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