SOAP Note and Differential Diagnoses for IHuman Case Carolyn Cross V3 (1 Solved Case)

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SOAP Note and Differential
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"Carolyn Cross V3 with
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SOAP Note and Differential Diagnoses for iHuman Case "Carolyn Cross V3
Name: Carolyn Cross Date: 05/21/2018 Time: 1020 AM
Age: 41 y /o Sex: F
BMI (27.5) Height 5’ 3’’ Weight 155 pounds
SUBJECTIVE
CC:
HPI: 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. She performs self-breast examines,
no lumps or bumps or discharged noted by patient. She reports breast tenderness around her
menstrual cycle.
Medications: Current Medications: She takes vitamin E for fibro cystic breast disease,
she had a mammogram 18 months ago.
PMH: Denies any health problems past or present, she had a mammogram 18 months ago.
Allergies: N/A
Medication Intolerances: “None at this time”
Chronic Illnesses/Major traumas. M. O. Denies any chronic illness or Major traumas at
this time
Other:
Immunization: Immunizations are up to date.
Family History
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.
Father has hyperlipidemia and HTN.
Social History (SH): Pt has a glass of wine every night. Her supper diet is traditional
Hispanic diet. She has two sons and a husband with no reported siblings. She gardens and
does house work for exercise.

ROS
General
Denies cough, night sweats. No recent weight
again. Or weight loss. Completed 2018.
Cardiovascular
Patient denies chest pain, no murmurs,
bruits, palpitations, orthopnea or edema
Heart –when palpating for PMI (Point of
Maxima/ Impact), the PMI is in the 5th
intercostal space (ICS) at the mid-clavicular
line (MCL)_
Skin
The skin is warm and dry. No rash, bruising
or cuts to skin and abnormal hair and nail
growth.
Blanching observed for Quincke’s test.
Respiratory
Denies “cough, hemoptysis, SOB,
pneumonia, wheezing and an exposure to
TB”
Eyes
Pt denies using glasses.
Red reflex bilaterally
Optic disks sharp
Gastrointestinal
Denies “N/V/D, constipation, Abdominal
pain, hemorrhoid, eating disorder”
Ears
Normal appearing external structures; no
deformities or edema.
No discharge noted
Normal-appearing external auditory canals.
Tympanic membrane translucent, non-
injected and pinkish-gray in color.
No scarring, discharge or purulence noted.
Normal landmarks. Normal mobility with
insufflation.
Genitourinary/Gynecological
Normal extemal genitalia
Parous introitus
Normal vaginal mucosa
• Cervical eversion (ectropion) without
friability; samples collected for Pap smear
No abnormal discharge
Uterus firm, slightly irregular in contour per
bimanual exam
• Adnexa difficult to palpate, nontender
Nose/Mouth/Throat
“Denies hoarseness, sinus problems, nose
bleeding”
No discharge or polyps
No edema or tenderness over the frontal or
maxillary sinuses.
Musculoskeletal
No asymmetry or deformity of the back
No tenderness or spasm of the paraspinal
muscles
No localized tenderness of the spinous
processes or pelvic structures.
Musculoskeletal - test Strength is 5/5
bilaterally (MRC scale; 0=complete
paralysis; 5= normal power)
Breast
Normal, symmetrical breast contour
No visible skin or nipple abnormalities
No spontaneous or expressed nipple
discharge or blood
Irregular "lumpy bumpy" consistency
throughout both breasts; no suspicious,
discrete palpable lesions
Slight, diffuse tenderness to exam reported
Neurological
Denies any neurological defect at this time.

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SOAP Note and Differential Diagnoses for IHuman Case Carolyn Cross V3 (1 Solved Case)

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