Posted: March 16th, 2022

“My left breast is painful.”

Episodic/Focused SOAP Note

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Episodic/Focused SOAP Note
Patient Information:
SA., 44, Female, Black.
S.
CC (chief complaint): “My left breast is painful.”
HPI: SA is a 44-year-old black female who presents to the clinic with complaints of pain in her left breast. She indicates that the left breast has normal size but with small lumps. The patient indicates that the pain in the left breast started three days ago. The right breast is not painful. SA indicates that the pain has been worsening causing discomfort and lack of sleep. She feels like a burning sensation. She noticed the pain after going on vacation. The pain is worse at night. She has been taking ibuprofen but without much relief. She rates the severity of pain at 8/10.
Current Medications:
Ibuprofen
Multivitamins 500mg daily
Allergies: Food allergies, cold allergies, and penicillin.
PMHx: Urinary tract infection, fibrocystic breast disease, and hypocalcemia.
Soc & Substance Hx: Patient operates a family-owned grocery with her husband. She is married to one husband and together they have two sons. She takes alcohol on weekends. She smokes at least five cigarette sticks daily.
Fam Hx: Her mother has breast cancer stage four and her father is deceased. Her elder sister died of breast cancer five years ago. Her only brother is healthy. Her husband and children have no significant medical history. No grandchildren yet.

Surgical Hx: Left ankle surgery (03. 2014)
Mental Hx: Patient has a history depression and anxiety during the left ankle surgical operation. No recurrent episodes. No history of self-harm or suicidal ideation.
Violence Hx: No history of violence at work or place of work.
Reproductive Hx: LMP is October 2021. No contraceptives or sexual concerns.
ROS:
GENERAL: The patient refutes weight changes, fever, fatigue, or chills.
HEENT: Refutes headache, vision loss, teary eyes, hearing loss, nasal congestion, or sore throat.
SKIN: No rashes or itching.
CARDIOVASCULAR: Denies chest pain, chest discomfort, or edema.
RESPIRATORY: No shortness of breath or cough.
GASTROINTESTINAL: No abdominal pain, vomiting, or diarrhea.
GENITOURINARY: No burning sensation or urination. LMP is October 2021.
NEUROLOGICAL: No headache, numbness, or changes in bowel movement.
MUSCULOSKELETAL: No muscle pain or stiffness.
HEMATOLOGIC: No bleeding or anemia.
LYMPHATICS: No history of splenectomy or enlarged nodes.
PSYCHIATRIC: History of depression in 2014 during left ankle surgery.
ENDOCRINOLOGIC: No sweating or cold intolerance, polyuria or polydipsia.
REPRODUCTIVE: No recent pregnancy. Last vaginal discharge in 2018 at her 49th birthday. She is sexually active.
ALLERGIES: Food allergies, cold allergies, and penicillin.

O.
Constitutional: T 97.8, BP 124/80, HR 74, RR 18 Ht 4” 9’, Wt 120lbs
General: The patient is well-groomed for the health visits and cooperates during the conversation.
Head: No deformities observed.
Eyes: No discharge, redness, or sclera white.
Ears: No discharge and bilaterally intact.
Nose: No sneezing, discharge, or moist mucosa.
Throat: No inflammation, dislocation or swelling.
Mouth: Oral mucosa is pink and moist.
Cardiovascular: No murmurs, RRR within range, S1 and S2 present.
Respiratory: No wheezing sound and chest is clear.
Gastrointestinal: No diarrhea and bowel sounds present in four quadrants.
Genitourinary: No painful sexual intercourse, no vaginal discharge, and no painful urination.
Musculoskeletal: No swelling and normal gait.
Neurologic: Normal gait and no abnormality in movement.
Psychiatric: No suicidal thoughts or insomnia.
Diagnostic results:
Mammogram test carried out. The patient is to wait for results until her next menstrual cycle. A mammogram test is an X-ray of the breast to detect early signs of breast cancer. Women above 40 years should take a mammogram test annually to enhance detection of breast cancer early. Early detection improves treatment and reduces the risk of adverse health outcomes.
Complete blood count test shows the cells in the blood are within normal range. CBC is effective in eliminating other causes of pain in the breast or any infection in the blood. Infections in the breast can cause pain.
A.
Differential Diagnoses
N64. 4 Breast cancer
Breast cancer is common among women above 50 years. It causes a painful lump although sometimes it may be painless. Symptoms include bloody nipple discharge and changes in the structure of the nipple (Lee et al., 2018). Treatment of the condition depends on the condition. Breast cancer is the most likely condition due to the genetic factor and the age of the patient. Breast cancer is hereditary and women above 50 years are more prone to the disease (Lee et al., 2018).
N60. 2 Fibroadenoma
Fibroadenoma is a non-cancerous tumor that occurs mostly in young women but it can be found in women of any age. The condition is caused by reproductive hormones (Akram et al., 2017). Timely treatment is essential since the condition can become cancerous. Fibroadenoma shrinks after a woman goes through menopause (Akram et al., 2017).
D24. 1 Intraductal papilloma
Intraductal papilloma is a type of growth that occurs in one of the milk ducts. The condition causes nipple discharge (Han et al., 2018). It can be painless but for some patients, it can cause pain and discomfort (Han et al., 2018).
N60. 29 Sclerosing adenosis
Sclerosing adenosis is a benign condition that occurs during the process of aging. The condition occurs when lobules grow larger than others. Sclerosing adenosis is associated with painful breasts.
N601 Fibrocystic breasts
Fibrocystic breasts was formerly known as a disease but research shows it is a condition common among women during the menstrual cycle (Akano et al., 2021). Although the cause is not clear, the closest suspicion is the hormonal changes during periods (Akano et al., 2021).
N60. 39 Stromal fibrosis
The condition involves the thickening of breast tissue. The condition can lead to painful breasts. The cysts build up fluids in the breast (Medeiros et al., 2018). The condition causes the growth of fibrous tissue.
P.
Mammogram breast examination carried out and the patient will get the results in the next follow-up clinic. A complete blood count shows that the patient has no infection in the blood that can trigger pain in the breast (Mathew et al., 2017). It will be important to refer the patient to a counselor due to the risk of stress and anxiety that may occur. Patients with breast cancer, malignant conditions are likely to experience depression or anxiety due to the stigma associated with the illness (Mathew et al., 2017). Cognitive behavior therapy is one of the best interventions since it can help the patient to enhance thinking patterns and emotions.
Health education is vital for patients with conditions affecting their reproductive organs such as breasts or cervix. Health promotion is effective to ensure the patient does not use risky methods to treat the condition such as herbal medicine (Farge & Frere, 2019). It is important to educate the patient after the mammogram results are released. It will be important to prescribe pain killers such as ibuprofen 400mg BID to relieve the pain. The patient should visit the healthcare facility after four weeks to collect the results and get appropriate treatment.
I agree with my preceptor about the diagnosis of the condition.
The case study of the patient demonstrates the need to study the health issues affecting women. I will strive to understand the health issues affecting women, the present symptoms, and relationships with other illnesses. In the future, I will strive to get additional information from the patient to ensure accurate treatment. For instance, I will enquire the lifestyle such as smoking and taking alcohol. Smoking and taking alcohol increase the risk of cancer (Farge & Frere, 2019). I will educate the patient about the effects of smoking on the risk of cancer and other conditions. The information should include the need to start early treatment if the diagnosis is positive and come for an annual checkup if the condition is negative for cancer (Medeiros et al., 2018). I will inform the patient about the treatment challenges for cancer which is already in advanced stages. Educating the patient will comprise informing them about the treatment options for the current condition, whether cancerous or not (Medeiros et al., 2018).
Provision of care will include taking care of the patient’s ethnic background. I will be sensitive to the needs of the patient as a black woman. Black women are at a high risk of discrimination and inequality in the healthcare sector (Hayes et al., 2019). I will avoid words or statements that can undermine the confidence of the patient.
During the delivery of care, I will observe ethical guidelines such as confidentiality of information. I will guarantee the patient that the information will remain confidential. Another ethical consideration is to take time to diagnose the patient to avoid medical errors (Salari & Larijani, 2017). Maleficence and beneficence are vital considerations to utilize utmost care to avoid mistakes that can put the life of a patient at risk (Salari & Larijani, 2017).
References
Akano, T. A., Fakinlede, O. A., & Nwoye, E. (2021). The Biomechanics of the Fibrocystic Breasts at Finite Compressive Deformation. In Journal of Biomimetics, Biomaterials and Biomedical Engineering (Vol. 49, pp. 33-45). Trans Tech Publications Ltd.
Akram, M., Iqbal, M., Daniyal, M., & Khan, A. U. (2017). Awareness and current knowledge of breast cancer. Biological Research, 50(1), 1-23.
Farge, D., & Frere, C. (2019). Recent advances in the treatment and prevention of venous thromboembolism in cancer patients: role of the direct oral anticoagulants and their unique challenges. F1000Research, 8.
Han, S. H., Kim, M., Chung, Y. R., La Yun, B., Jang, M., Kim, S. M., … & Park, S. Y. (2018). Benign intraductal papilloma without atypia on core needle biopsy has a low rate of upgrading to malignancy after excision. Journal of breast cancer, 21(1), 80-86.
Hayes, L., Forrest, L., Adams, J., Hidajat, M., Ben-Shlomo, Y., White, M., & Sharp, L. (2019). Age-related inequalities in colon cancer treatment persist over time: a population-based analysis. J Epidemiol Community Health, 73(1), 34-41.
Lee, S. E., Han, K., Kwak, J. Y., Lee, E., & Kim, E. K. (2018). Radiomics of US texture features in differential diagnosis between triple-negative breast cancer and fibroadenoma. Scientific Reports, 8(1), 1-8.
Mathew, B., Hobrath, J. V., Connelly, M. C., Guy, R. K., & Reynolds, R. C. (2017). Diverse amide analogs of sulindac for cancer treatment and prevention. Bioorganic & medicinal chemistry letters, 27(20), 4614-4621.
Medeiros, C. S., Marino, G. K., Santhiago, M. R., & Wilson, S. E. (2018). The corneal basement membranes and stromal fibrosis. Investigative ophthalmology & visual science, 59(10), 4044-4053.
Salari, P., & Larijani, B. (2017). Ethical issues surrounding personalized medicine: a literature review. Acta Medica Iranica, 209-217.

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