NURS 522
i-Human
Comprehensive SOAP
Note
Date of Visit: July 21, 2022
Patient Name: Carolyn Cross
Patient Age: 41 y/o
Subjective
41- year-old female who presents today for a well-woman examination and to discuss risks for breast cancer.
HOPI: Carolynn Cross is a 41-year-old G2P2 female of Hispanic descent who presents to the clinic for a well-
woman examination after her mother, age 63, and first cousin, age 44, were both recently diagnosed with
intraductal breast cancer. She currently does not have any symptoms/complaints and is an overall healthy state.
Patient has a history of fibrocystic breast changes, reports “lumpy” breasts for long as she can remember and
performs self-breast examinations which have not revealed any new findings. She began menses at age 10.5,
her cycle is 25-26 days without any bleeding in between, but endorses breast tenderness around menstruation,
and the last period was two weeks ago. Both her deliveries were normal, but she had a tubal ligation after her
last delivery at 35-years-old. Her previous gynecological exam was 3 years ago and normal and she has no
history of sexually transmitted diseases. Patient’s first mammogram 18 months ago at age 40 showed no
changes, and all Pap smears have been normal. She is currently concerned about her risk for breast cancer after
two of her first-degree relatives have been diagnosed with breast cancer.
History:
Medical: Fibrocystic breast changes
Hospitalizations/ Surgeries:
• Two previous hospitalizations for delivery of each of her children
• Bilateral tubal ligation following last delivery at age 35
• Minor dental procedures and regular cleanings every 6 months (Surgery, year of
surgery, complications/no complications)
• No significant trauma/injuries
GYN/OB:
• G2P2; NSVD x two and breast fed both for 4 months
• Started menses at age 10.5, regular cycle is 25-26 days without any bleeding in between, and last period
was 2 weeks ago
• No history of sexually transmitted diseases
• Fibrocystic breasts, no new lumps/discharge or skin dimpling or retractions on the breasts
• Last gynecological exam 3 years ago
• First mammogram 18 months ago at the age of 40 was normal and Pap smears have been normal
Family Hx:
• Mother (living) diagnosed with intraductal breast cancer two months ago at age 63, followed by a
lumpectomy and currently undergoing radiation
• M o t h e r ( li v i n g ) h is to r y o f t y p e 2 d i a b e te s
This stu dy so urc e w a s do w n lo a de d by 1 00 00 0 85 79 8 5 93 7 fr om C o u rs eH e ro.com on 03-23-2023 02:51:58 GMT -
https://www.coursehero.com/file/159767420/NUR-522-Carolyn-Cross-SOAP-Notedocx/
, NURS 522
05:00
https://www.coursehero.com/file/159767420/NUR-522-Carolyn-Cross-SOAP-Notedocx/
i-Human
Comprehensive SOAP
Note
Date of Visit: July 21, 2022
Patient Name: Carolyn Cross
Patient Age: 41 y/o
Subjective
41- year-old female who presents today for a well-woman examination and to discuss risks for breast cancer.
HOPI: Carolynn Cross is a 41-year-old G2P2 female of Hispanic descent who presents to the clinic for a well-
woman examination after her mother, age 63, and first cousin, age 44, were both recently diagnosed with
intraductal breast cancer. She currently does not have any symptoms/complaints and is an overall healthy state.
Patient has a history of fibrocystic breast changes, reports “lumpy” breasts for long as she can remember and
performs self-breast examinations which have not revealed any new findings. She began menses at age 10.5,
her cycle is 25-26 days without any bleeding in between, but endorses breast tenderness around menstruation,
and the last period was two weeks ago. Both her deliveries were normal, but she had a tubal ligation after her
last delivery at 35-years-old. Her previous gynecological exam was 3 years ago and normal and she has no
history of sexually transmitted diseases. Patient’s first mammogram 18 months ago at age 40 showed no
changes, and all Pap smears have been normal. She is currently concerned about her risk for breast cancer after
two of her first-degree relatives have been diagnosed with breast cancer.
History:
Medical: Fibrocystic breast changes
Hospitalizations/ Surgeries:
• Two previous hospitalizations for delivery of each of her children
• Bilateral tubal ligation following last delivery at age 35
• Minor dental procedures and regular cleanings every 6 months (Surgery, year of
surgery, complications/no complications)
• No significant trauma/injuries
GYN/OB:
• G2P2; NSVD x two and breast fed both for 4 months
• Started menses at age 10.5, regular cycle is 25-26 days without any bleeding in between, and last period
was 2 weeks ago
• No history of sexually transmitted diseases
• Fibrocystic breasts, no new lumps/discharge or skin dimpling or retractions on the breasts
• Last gynecological exam 3 years ago
• First mammogram 18 months ago at the age of 40 was normal and Pap smears have been normal
Family Hx:
• Mother (living) diagnosed with intraductal breast cancer two months ago at age 63, followed by a
lumpectomy and currently undergoing radiation
• M o t h e r ( li v i n g ) h is to r y o f t y p e 2 d i a b e te s
This stu dy so urc e w a s do w n lo a de d by 1 00 00 0 85 79 8 5 93 7 fr om C o u rs eH e ro.com on 03-23-2023 02:51:58 GMT -
https://www.coursehero.com/file/159767420/NUR-522-Carolyn-Cross-SOAP-Notedocx/
, NURS 522
05:00
https://www.coursehero.com/file/159767420/NUR-522-Carolyn-Cross-SOAP-Notedocx/
