SOAP NOTE
Student Name: Course: NSG6430
Name: J.M. Date: 03/05/24 Time: 1630
Ethnicity: Black Age: 52 Sex: F
SUBJECTIVE
CC: “I have a lump on my breast that doesn’t hurt for 3 weeks.”
HPI: The patient reports first noticing the lump approximately 3 weeks ago. She denies any
associated pain, redness, discharge, or changes in the skin over the lump. She has not
noticed any similar lumps elsewhere on her body. The patient denies any recent trauma or
injury to the breast area.
Medications: (list with reason for med )
Amlodipine 10mg daily
PMH
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: Hypertension
Hospitalizations/Surgeries- Tubal ligation, colonoscopy
Family History
M: Alive- 78 years old- breast cancer dx at age 60
MGM: Deceased
MGF: Deceased
F: Unknown
PGM: Unknown
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:07:25 GMT -05:00
https://www.coursehero.com/file/235913166/NSG6430-Week-4-SOAP-Costa-Cdocx/
, PGF unknown
Social History
The patient is a community patrol officer who reports she has never smoked and drinks
alcohol occasionally, specifically one glass of wine on weekends. She denies any illicit drug
use and mentions that she enjoys walking and reading in her leisure time. The patient lives
with her husband and two children in a suburban area.
ROS
General Cardiovascular
Patient denies night sweats, fatigue or weakness Denies any chest pain or shortness of breath,
Skin Respiratory
No rash, lesions, or other skin abnormalities Deferred
Eyes Gastrointestinal
Deferred Deferred
Ears Genitourinary/Gynecological
Deferred Deferred
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:07:25 GMT -05:00
https://www.coursehero.com/file/235913166/NSG6430-Week-4-SOAP-Costa-Cdocx/
Student Name: Course: NSG6430
Name: J.M. Date: 03/05/24 Time: 1630
Ethnicity: Black Age: 52 Sex: F
SUBJECTIVE
CC: “I have a lump on my breast that doesn’t hurt for 3 weeks.”
HPI: The patient reports first noticing the lump approximately 3 weeks ago. She denies any
associated pain, redness, discharge, or changes in the skin over the lump. She has not
noticed any similar lumps elsewhere on her body. The patient denies any recent trauma or
injury to the breast area.
Medications: (list with reason for med )
Amlodipine 10mg daily
PMH
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: Hypertension
Hospitalizations/Surgeries- Tubal ligation, colonoscopy
Family History
M: Alive- 78 years old- breast cancer dx at age 60
MGM: Deceased
MGF: Deceased
F: Unknown
PGM: Unknown
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:07:25 GMT -05:00
https://www.coursehero.com/file/235913166/NSG6430-Week-4-SOAP-Costa-Cdocx/
, PGF unknown
Social History
The patient is a community patrol officer who reports she has never smoked and drinks
alcohol occasionally, specifically one glass of wine on weekends. She denies any illicit drug
use and mentions that she enjoys walking and reading in her leisure time. The patient lives
with her husband and two children in a suburban area.
ROS
General Cardiovascular
Patient denies night sweats, fatigue or weakness Denies any chest pain or shortness of breath,
Skin Respiratory
No rash, lesions, or other skin abnormalities Deferred
Eyes Gastrointestinal
Deferred Deferred
Ears Genitourinary/Gynecological
Deferred Deferred
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:07:25 GMT -05:00
https://www.coursehero.com/file/235913166/NSG6430-Week-4-SOAP-Costa-Cdocx/
