SOAP Note 4

Subjective:

HPI: 30 y/o female G3P2001 at 15 weeks with no significant PMH s/p excisional biopsy in Guyana (5/6/23) for right breast mass showing invasive papillary carcinoma, s/p right breast sonocore biopsy x2 on (8/17/23) in U.S. showing a 1.3 cm mass at 11 o’clock and large mass at 10 o’clock concordant with pathology report which reports sclerosing adenosis and focal fibroadenomatous changes at 11 o’clock and invasive ductal carcinoma, grade 3, triple negative at 10 o’clock, presents to breast surgery clinic today for follow up post biopsy. Pt reports biopsy sites are healing fine without complaints, but notes feeling sharp pain in axilla and right breast with palpation. Denies any skin changes, nipple discharge or bleeding, new palpable masses, fever, chills, nausea, vomiting, or diarrhea. Pt interested in what her next steps are considering she is 15 weeks pregnant and does not wish to terminate pregnancy.

Past Medical History:

  • No past medical history

Surgical History:

  • Excisional biopsy, right breast mass (5/6/23)
  • Sonocore biopsy, right breast masses (8/17/23)
  • Denies any blood transfusions

Family History:

  • Denies family h/o breast or ovarian cancer.

Social History:

  • Denies smoking history
  • Drink drinking alcohol
  • Denies drug use

Medications:

  • Currently not on any medications

Allergies:

NKDA

ROS:

Constitutional: Negative for chills, fever, malaise, fatigue

Skin: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, pruritus, moles/rashes

HENT: Negative for headaches, dizziness, nose bleeds, bleeding gums, and loose teeth. Denies use of hearing aids

Eyes: Denies use of glasses or blurry vision

Respiratory: Negative for cough, shortness of breath, wheezing, dyspnea on exertion, hemoptysis

Cardiovascular: Negative for chest pain, edema/swelling or ankles or feet, syncope or known heart murmur

Breast: Denies new lumps, nipple discharge. Admits to right axillary pain.

Gastrointestinal: Denies abdominal pain, vomiting, diarrhea or constipation. 

Musculoskeletal: Negative for muscle/joint pain from arthritis. Denies deformity, swelling or redness

Neurological: Negative for seizures, headache, ataxia, loss of strength, change in cognition/mental status/memory or weakness

Endocrinology: Denies excessive thirst, heat/cold intolerance, changes in hair pattern, polyuria, polydipsia, polyphagia

Hematology: Denies anemia easy bruising, history of blood transfusions

Psychiatric/Behavioral: Denies anxiety or depression

Objective

Physical Exam: 

Vitals Signs:

Temp: 37.3 degrees Celsius

HR: 87

RR: 17

SpO2: 100%

BP: 108/75

Wt: 61.2 kg

Ht: 1.51 m

BMI: 28.1

General: Appears clean & casually groomed, alert & oriented to time, place and person. Seems like a reliable source of information. Does not appear to be in acute distress. Pt appears stated age.

HEENT: normocephalic, atraumatic

Skin: warm and dry 

Heart: Regular rate and rhythm, S1 and S2 are distinct with no murmurs, S3, or S4. No splitting of S2 or friction rubs appreciated.

Lungs: clear to auscultation bilaterally. No wheezes, rales or rhonchi. No respiratory distress.

Breast: Right breast: previous biopsy incision site healed, new biopsy sites healing, no nipple discharge noted, palpable breast masses in right upper outer quadrant at 11 o’clock 4cm from nipple and at 10 o’clock, tender to palpation, Right Axilla: tenderness to palpation, no palpable lymph nodes, Left Breast: no dimpling, no discharge, or skin changes noted. No masses to palpation, no axillary nodes palpable

Abdominal: flat and symmetric, no distention, no scars, striae, or pulsations noted. Abdomen soft. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. No tenderness to palpation, (-) Murphys sign, (-) guarding. (-) obturators sign, (-) psoas signs, (-) rebound tenderness. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.  

Neurological: A&Ox3. No sensory deficits

Imaging:

Assessment:

30 y/o female s/p right breast sonocore biopsy x 2 showing one benign finding and with right breast triple negative invasive ductal carcinoma. Patient is open to surgery. Will need to be seen by plastic surgery prior to surgery

Plan:

  • Discussed test results and treatment options with patient. Pt expressed understanding.
  • Order CBC, BMP, PT-INR,  APTT 
  • F/u with plastic surgery clinic 9/6/23