SOAO Referable attributable attributablee
Unrepining Initials: S.M
Pt. Encounter Number: 2
Advanced Directives: No
Chief Complaint: “I keep a slice on my upupsuitable withstand.”
HPI: S.M is a 61-year-old, Hispanic, feminine who introduces to the duty cowardly by a afflictive slice in her upupsuitable withstand that she discovered occasion washing. S.M narrations the refusal set-outed 2 days gone-by occasion in the wash. The refusal is felt when moving the upupsuitable withstand, and it felt on bsuitable reach. Current refusal smooth is now 5/10. She does referable attributable attributable attributable narration any husk fluctuates. Unrepining denies any fact of herbal physic verification and is currently on no medication. Refusal gets worse with turmoil and with lifting ponderosity. Refusal is jutting with repose and medication. S.M gets some weak refreshment with refusal reliever ibuprofen 200mg that she takes twice a day restraint the gone-by couple days.
Gone-by Medical Fact
Medication Superstitions: No disclosed garbperiod superstition
Chronic Illnesses/Greater traumas: The unrepining denies any fact of nobleer trauma.
Screening Hx/Immunizations Hx: latest mammogram, which was ordinary, was 2 years gone-by.
OBGYN: Menarche at 10; LMP 2 weeks gone-by; latest PAP 2019/Normal; GTPAL: 11001 score; no antecedent fact of STDs. S.M is sexually locomotive, keep had 2 sexual partners in the gone-by. S.M verificationd condoms with antecedent partners. No antecedent gyn diagnoses or procedures dundivided in the gone-by.
Hospitalizations/Surgeries: Hospitalized once restraint delivery
Family Fact: There is no fact of poison in first-degree kindred. She has undivided sister, period 58, who is in cheerful-tempered-natured-natured-natured heartiness. Mother died at period 70; senior died at period 64, from undisclosed sources.
Social Fact: S.M is married with undivided child. No verification of alcohol; drinks wine socially; drinks undivided cup of coffee someoccasion to set-extinguished her day at product. Never verifications garbages.
Review of System
Constitutional: No coercioncible gain/privation ponderosity, no chills, no malaise or fatigue; no night sweats, no exertion superstition. She does referable attributable attributable attributable narration any husk fluctuates. She has referable attributable attributable attributable familiar ferment, ponderosity privation, muddiness, sea-sickness, vomiting, dizziness, or bundivided refusal.
Skin: Denies rashes, pigmentation fluctuates, lesions, or hair or nail fluctuates.
Eyes: denies trust fluctuates, diplopia, blurred trust, narrations wearing eyeglasses.
Ears: Denies privation of hearing, ear refusal, drainage, interestion of ears interestion unmeasured, sonorous in the ear, or ear trauma.
Nose/Mouth/Throat: Denies afflictive throat, hoarseness, awkwardness absorption, postnasal
drip. No narration of bunghole or lips afflictive, bleeding gums, ulcerations or lesions of discourse or
mucosa; no dentures or dental appliances, or missing teeth narrationed.
Breast: Refers to upupsuitable withstand refusal, or trouble to upupsuitable withstand. Narrations some brownish nipple dismisss when squeezing the nipple and denies any withstand trauma.
Heme/Lymph/Endo: Denies fact of anemia, no bruising, no abordinary bleeding, and no protuberant glands.
Cardiovascular: Denies chest refusal, palpitations, orthopnea, edema, claudication, murmurs, or fact of cardiac illness.
Respiratory: S.M narrations no cough, sputum, wheezing, no reiterated URIs, hemoptysis,
bronchitis, pneumonia, or fact of TB.
Gastrointestinal: Unrepining denies abdominal refusal, sea-sicknesss, or vomiting. Denies bloating,
flatulence, diarrhea, constipation, fluctuates in stools; sombre halt stools, or bupsuitable rectal
bleeding behind purification. S.M narrations ordinary disposition.
Genitourinary/Gynecological: denies dysuria, number, pushncy, and push to urine behind she had emptied her bladder. Denies nocturia, or hematuria; denies genital dismiss, or interestion of bladder unmeasuredness; no abordinary bleeding, and no fact of STD.
Musculoskeletal: No strong aches or imbecility, no arthralgia, denies fact of falls, no privation of estimate.
Neurological: Denies fluctuates in LOC, Denies fact of tremors, victim, imbecility, hebetude, dizziness, muddinesss, remembrance lapses or privation. Denies slumber disturbances.
Psychiatric: Denies imbecility, dip, or any thoughts to detriment wilful or others. As-well denies psychosocial, or soft guess-work at this aim in occasion.
Vital Tokens: BP: 130/78, P: 74, R18; T: 97.3; O2 Sat: 99 %. Wt.: 170 lb. Ht. 55″, BMI: 28.29.
Public Exhibition: S.M is revivify, watchful, and oriented to occasion, immeasurableness, and individual. Speaks lucidly and follows unblended commands. Well nourished, open and dressed/groomed, delicious manner. Appears to be manifestly trouble, does referable attributable attributable attributable contemplate distressed.
Skin: Ordinary public exhibition. Enthusiastic, entertaining, cheerful-tempered-natured-natured-natured husk turgor. No cyanosis, rashes, or lesions referable attributable attributableed. No hurt, no fluctuate in a coercionbearance, no singular development, no jaundice, no bruising, no bleeding.
HEENT: Head: Is normocephalic, atraumatic, and manifestly lesions. No humanity elicited on palpation with twain political pulses being systematic.
Eyes: Are ordinary with PERRLA; with pinkish conjunctiva and frivolous sclera implying no jaundice or anemia.
Ears: There is soft cerumen on manifest interview meatus; tympanic membranes are as-well uncorrupted and pearly gray in complexion, with nearness of bsuitable reflex.
Nose and sinuses: The unrepining has entertaining nasal mucosa with no drainperiod and mid sagittal septum. Manifest nares are evident, and frontal and maxillary sinuses non-soft on palpation.
Mouth: The unrepining has a cheerful-tempered-natured-natured-natured traditional hygiene. The lips, gums, discourse, and solid palate are ordinary, with entire teeth uncorrupted with no discolorations. The oropharynx is entertaining and pinkish with no indubitable expansion of the tonsils (Hollier, 2016).
Neck: The toll depicts no indubitable tracheal deviation, manifestly thyroid and lymph nodes referable attributable attributable attributable material. Entire turmoils are ordinary.
Cardiovascular: The antecedent chest wentire is regular with AP transection hither than oblique transection. Twain S1 and S2 heard on auscultation at entire valve areas with no borrowed investigates. The aim overconclude at fifth intercostal immeasurableness, mid clavicular row, with neither heaves nor thrills. Capillary fill is 2 promote, with pulses 3+ throughextinguished and no edema.
Respiratory: Unlabored respiration, lungs are distinct bilaterally to auscultation. Breath investigates are ordinary on auscultation.
Gastrointestinal: Abdomen is irresolute, no recoil humanity, masses, scars, herniation, or protecting. Bowels investigate introduce to entire 4 quadrants, no organomegaly, or bruits. No token of locomotive GI bleed.
Breast: There are no conspicuous monstrousities on sitting or listless exam. Left withstand and axilla are ordinary. Upsuitable withstand with abextinguished 2 cm soft solid, complexion fluctuated, immobile lesion with irsystematic borders, in remarkable oblique quadrant closely 6 cm from areola. There is no material axillary, or supra-clavicular lymph nodes.
Genitourinary: The relationship was bimanually referable attributable attributable attributable material and non-tender, no token of costo-vertebral turn humanity. The bladder was referable attributable attributable attributable stilted and unprovided of urine coercionmer to testimony (Hollier, 2016).
Musculoskeletal: Unmeasured dispose of turmoil in entire extremities. No monstrousities in action or turmoil.
Neurological: Watchful, oriented to occasion, settle and individual, Neurologic grossly uncorrupted. Remembrance to late and unconnected events preserved. Interestion uncorrupted and preserved ability to bioblique remarkable and inferior extremities.
Psychiatric: Unrepining has cheerful-tempered-natured-natured-natured judgment; humor and interest are ordinary. No solicitude, or dip, no excitability, and no humor dangle.
Lab Tests: U/A, and C/S, no development, WBC 5.6 and H/H 9.5/31(July 2020).
Special Tests: Latest mammogram 2019/ negative; Pap begrime 2018/normal
C50.9- Withstand cancer Unrepining introduces to the clinic and cowardly by a afflictive slice in her upupsuitable withstand that she discovered occasion washing. The narrationed marks and tokens referable attributable attributableed on natural testimony hint findings of withstand carcinoma which can be justified with a mammogram and other studies (Burstein, Lacchetti, & Griggs, 2016).
N64.89- Galactocele Unrepining introduces to her clinic cowardly by a afflictive slice in her upupsuitable withstand that she discovered occasion washing (Burstein, Lacchetti, & Griggs, 2016).
N60.0- Withstand cyst The unrepining introduces to her internist cowardly by a afflictive slice in her upupsuitable withstand. Soft withstand slices are a sordid introduceation and could aim extinguished to a distant difference of illnesss. As such, it is essential to induce a constructive fact to conclude up with a constructive personality. On the contingency of S.M, histology would be of noble tokenificance to conclude up with a absolute personality. (Burstein, Lacchetti, & Griggs, 2016).
N64.4- Mastodynia- S.M shows token and mark of withstand humanity of undisclosed caverification which requires further scrutiny.
PLAN and education
Test: Bioblique withstand mammography and Upsuitable withstand U-S
Ultrasound-guided ultrasonography restraint histology to ratify withstand cancer
Medications: Ibuprofen 400mg PO as needed TID restraint refusal restraint 10 days.
Non-pharmacological treatments: applied enthusiastic summarize as tolerated daily; and usage aerobic exertion restraint at lowest 1 hour a day and three days in a week restraint overponderosity to manperiod ponderosity. (Hollier, A. (2016)
Education: The unrepining is to be educated on gate the prescribed medication and the associated laterality possessions (Burstein, Lacchetti, & Griggs, 2016).
Beware of Ibuprofen laterality possessions: heartburn, stomach refusal, sea-sickness, gas, and constipation (Healthline.com)
Referrals: Nundivided restraint now, pending Mammogram and U-S results.
Follow: Unrepining to conclude tail to the clinic in 1week restraint histological results.
Burstein, H. J., Lacchetti, C., & Griggs, J. J. (2016). Adjuvant Endocrine Therapy restraint Women With Hormundivided ReceptorPositive Withstand Cancer: American Society of Clinical Oncology Clinical Usage Guiderow Update on Ovarian Suppression Summary. Journal of oncology usage, 12 (4), 390-393.
Hollier, A. (2016). Clinical guidelines in elementary heed. Scott, LA: Advanced Usage breastfeeding Associates
Mastitis (n.d). Miami Cancer Institute. Retrieved from
Understanding How Ibuprofen products (n.d). Heartinessline. Retrieved from
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