Description

SOAP Note and Differential Diagnoses for iHuman Case "Carolyn Cross V3 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