Breast Cancer SOAP note Name Sharon Broom Date: January/17/2020. Age: 45 years old Gender: Female Time:12:45 SUBJECTIVE: Chief Complaint: “I have a sore lump on the left breast." History of Present Illness: Sharon is a 45-year-old female with complaints of a painful lump on her left breast for a month. The patient indicates that she feels unbalanced lumps on her left breast that are painful on the outer and upper corners. The patient observed the areas of the left outer breast worsening in terms of size and pain in the past week. She has experienced the pain of level four out of ten. Her mother was detected to have breast cancer prior to the age of 50. She has had a history of hysterectomy because of irregular periods, menorrhagia. The patient refutes swelling, increased warmth, and redness of the left breast. She repudiates nipple discharge swollen glands, chills, and fever. History Past Medical History: Fibrocystic breast disease, Vitamin D deficiency, Urinary tract infection, Hypothyroidism, Hypocalcemia, and Constipation Screenings: Blood Pressure screening (2016 N/A) Dental Examination (2016 N/A) Eye Examination (2016 N/A) Mammogram (2016 BiRad 2) Pap smear- normal HPV test- normal GTPAL: G=1.T=0. P=0. A=0. L=1 (Normal vaginal delivery without complication) Menstrual Hx: started at the age of 14. Normal PAP outcomes. LMP (cannot recall)-hysterectomy (07.2012) Post Hospitalizations: Admitted to hospital for hysterectomy for one week Past Surgical History: Hysterectomy (07. 2012) Medications: Armour Thyroid 30mg oral tablet: consume two pills on Monday, Wednesday, and Friday and three pills other days. Therapy: 15 May 2015 Last Rx: 5 April 2016 Allergies: Food allergies, Penicillin Triple Sulfa Vaginal CREA Family History: The patient’s mother passed away at the age of fifty, with a medical history of breast cancer. Sharon’s father is still alive at the age of seventy, with a medical record of hypertension. The patient has a younger brother aged 35 years and has no medical glitches. The patient has a sixteen-year-old son, who is healthy. Social History: The patient is divorced, and she lives with her son. She does not smoke but consumes alcohol irregularly. Sharon takes a regular diet that has no restrictions. She has no worries about weight loss or gains since she exercises two to three times weekly. The patient continually puts on a seatbelt when driving, wears sunscreen. Sexual/Contraceptive History: She has not been sexually active for at least a year, but previously, she had a monogamous relation. Birth control: Utilized condoms before. The patient has no fears with sexual performance or feelings. ...

1. Breast Cancer SOAP note
Name Sharon Broom
Date: January/17/2020.
Age: 45 years old
Gender: Female
Time:12:45
SUBJECTIVE:
Chief Complaint:
“I have a sore lump on the left breast."
History of Present Illness:
Sharon is a 45-year-old female with complaints of a painful
lump on her left breast for a month. The patient indicates that
she feels unbalanced lumps on her left breast that are painful on
the outer and upper corners. The patient observed the areas of
the left outer breast worsening in terms of size and pain in the
past week. She has experienced the pain of level four out of ten.
Her mother was detected to have breast cancer prior to the age
of 50. She has had a history of hysterectomy because of
irregular periods, menorrhagia. The patient refutes swelling,
increased warmth, and redness of the left breast. She repudiates
nipple discharge swollen glands, chills, and fever.
History
Past Medical History:
Fibrocystic breast disease, Vitamin D deficiency, Urinary tract
infection, Hypothyroidism, Hypocalcemia, and Constipation
Screenings:
Blood Pressure screening (2016 N/A)
Dental Examination (2016 N/A)

2. Eye Examination (2016 N/A)
Mammogram (2016 BiRad 2)
Pap smear- normal
HPV test- normal
GTPAL: G=1.T=0. P=0. A=0. L=1 (Normal vaginal delivery
without complication)
Menstrual Hx: started at the age of 14. Normal PAP outcomes.
LMP (cannot recall)-hysterectomy (07.2012)
Post Hospitalizations: Admitted to hospital for hysterectomy for
one week
Past Surgical History: Hysterectomy (07. 2012)
Medications:
Armour Thyroid 30mg oral tablet: consume two pills on
Monday, Wednesday, and Friday and three pills other days.
Therapy: 15 May 2015
Last Rx: 5 April 2016
Allergies:
Food allergies, Penicillin Triple Sulfa Vaginal CREA
Family History:
The patient’s mother passed away at the age of fifty, with a
medical history of breast cancer. Sharon’s father is still alive at
the age of seventy, with a medical record of hypertension. The
patient has a younger brother aged 35 years and has no medical
glitches. The patient has a sixteen-year-old son, who is healthy.
Social History:
The patient is divorced, and she lives with her son. She does not
smoke but consumes alcohol irregularly. Sharon takes a regular
diet that has no restrictions. She has no worries about weight
loss or gains since she exercises two to three times weekly. The

3. patient continually puts on a seatbelt when driving, wears
sunscreen.
Sexual/Contraceptive History:
She has not been sexually active for at least a year, but
previously, she had a monogamous relation. Birth control:
Utilized condoms before. The patient has no fears with sexual
performance or feelings.
Travel History:
She has not travelled out of the U.S.
Immunizations:
All her childhood and adulthood vaccinations are up to date
Review of Systems (Subjective):
General. The patient refutes fever, fatigue, or chills.
Skin, hair, nails: Repudiates excessive sweating, change in
texture, or pigmentation. Refutes changes in nails, hair, and
skin
HEENT: Refutes vertigo or headaches. No complaints of vision
loss, tearing, redness, or eye discharge. No criticisms of hearing
loss, swallowing difficulty, and ear drainage. Denies rhinorrhea
or nasal congestion — no bleeding gums.
Neck: Refutes swollen glands, pain, or lumps. Repudiates
discomfort of the neck
Respiratory: Repudiates shortness of breath, wheezing, or
cough.
Cardiovascular: No latest EKG. Refutes chest pain, palpitations,
dyspnea, and orthopnea
Gastrointestinal: Normal appetite, no diarrhea, indigestion,
reflux, vomiting, and nausea. Denies liver or gallbladder

4. problem, jaundice. Regular bowel movement. No abdominal
pain.
Genitourinary: Refutes vaginal discharge, itchiness, irritation,
and discomfort. Denies pain or burning when urinating,
suprapubic or flank pain hematuria, and dysuria. Repudiates
hesitation or urgency to urinate.
Breast
: Senses uneven lumps on her left breast,
extremely aching on the outer, upper corner of her left breast
Musculoskeletal: Refutes pain on joints, muscles, and bones.
Refutes constraint to a range of motion, weakness, stiffness and
joint swelling
Extremities: No bony defect on the joints, heat or redness
Neuro/Psychiatric: Repudiates any trouble of concentrating or
behavioural changes. Denies motor-sensory loss, seizures or
fainting. Refutes hallucinations, suicidal ideation, mood swings,
and depression.
Hematologic: Repudiates easy bleeding or bruising.
Endocrine: Denies kidney problems, thyroid problems, and a
history of diabetes. Denies tenderness or thyroid enlargement,
no inexplicable weight loss, or gain.
Objectives
Weight: 130 lb
Temp: 96.9 F
BP: 116/85
Height: 5.9”
Pulse:60

5. Resp: 15
Constitutional: refutes night sweats, irritability, weakness,
weight change, insomnia, anorexia, fatigue, chills, and fever
Mental status: Well-dressed patient who looks like her declared
age. Seems to be hydrated and well-nourished and does not look
to be intensely unwell. She is mild distress, oriented and alert.
Skin: the palms colour are normal for her ethnicity; they are
warm. No clubbing observed — similar pigmentation. Great
skin turgor. No nevi or rashes observed — scalp with no
lesions. Hair texture is average. Nail beds pink; great capillary
refill < 2 seconds. Moist mucus membranes and pink in the
mouth.
HEENT:
Head: Head midline and erect. Smooth with no deformities,
symmetric, atraumatic and normocephalic. Symmetric facial
features. Hair of midline texture.
Eyes: Conjunctiva sclera white, pink. The lens and cornea are
clear. Pupils are of equal size, regular and round, equally
sensitive to the light like constricting and dilating, and bilateral
accommodation. Intact peripheral visual fields. Intact
extraocular movements. Present red reflex.
Ears: the obes do not have tenderness, lesions, or masses —
clear bilateral ear canals. Tympanic membranes have good cone
of light, intact and pearly grey. Hearing intact. Right
perspicacity to whispered voice. Light reflex and bony
landmarks envisaged bilaterally.
Nose: No polyps or discharge, mucosa moist and pink. Patent
bilaterally and septum midline. No tenderness of sinus with
palpation. The right and left nostrils differentiate dissimilar

6. smells.
Throat: No tonsillar exudate or edema. Posterior oropharynx
with no erythema. Midline uvula. Mucous membranes moist and
pink with no ulceration. Gingiva firm and pink. Good dentition.
Tongue midline, no tenderness or ulcers present.
Neck: No carotid bruits, trachea midline, the neck is supple.
Lymph Nodes: No lymphadenopathy on lymph nodes in the
axillae and neck
.
Cardiovascular: No overall cyanosis or edema. Heart sounds of
S1 and S2 are audible with no gallops, rubs, or murmurs. No
noticeable cyanosis or JVD. Equal pulses, bilateral in all
extremes. No heaves, lifts, or thrills sensed on palpation.
Respiratory: Respirations regular rhythm and rate, equally
bilateral, and non-laboured. No unilateral lag, struggle of
breathing or extreme depth. Diminished lungs at the bilateral
bases; clear to auscultation. No perceptible adventitious breath
sounds, rhonchi, rales (crackles), or wheezes.
Chest/breast: No chest wall abnormalities. No reduced chest
expansion or chest pain; symmetrical chest expansion. No barrel
chest, localized rigidity or deformities. Percussion: no rise,
fremitus, hyper resonance, or dullness. Palpation: no crepitus,
tenderness, or abnormal tactile fremitus.
No skin changes, dimpling, symmetrical appreciated. Normal
nipples. Multiple nodules on the left breast. Palpated-Superior
tender mass, fluctuant, and lateral quadrant. Inferior tender
mass, quadrant fluctuant and lateral.
Abdomen: Soft abdomen. No deep palpation, light or rigidity,
tenderness or pain on other areas. Positive bowel sounds on
auscultation in the quadrants. No venous hum, renal bruits,

7. aortic or friction rubs. No ecchymosis, pulsations, ascites and
masses. No splenomegaly or hepatomegaly.
Genital/Urinary: No protests of itching or vaginal discharge. No
pain or burning during urination, suprapubic pain, flank,
hematuria, or dysuria. No urgency or hesitation on urination. No
bleeding during intercourse, discomfort, or pain.
Peripheral Vascular: Refutes bleeding or easy bruising.
Musculoskeletal:
Motor: Great tone and muscle bulk. Strength 5/5 all over. Gait
steady. Intact point-to-point movements, Cerebellar Rapid
alternating movements (RAMs).
Sensory
: Romberg negative. Intact 2-point
discrimination, vibration, position sense, light touch, and
pinprick.
Reflexes
: 2+ (brisk) plantar, Achilles, patellar, deep
tendon reflexes of brachioradialis, triceps and biceps.
Psychiatric: appropriate behaviour for her age
Neurological: cooperative, oriented, alert, awake. Clear speech.
Oriented to time, place as well as a person. Coherent thoughts.
(Mertins, et al., 2016).
LABS&IMAGING
The latest mammography showed no evidence of mammographic
malignancy. (BiRad2)
ASSESSMENT
Working diagnosis
Fibrocystic breast disease
Differential diagnosis

8. Mastitis, Fibroadenoma and breast cancer
Rationale
She has all progression and characteristics conforming with the
disease.
Several breast lumps on the breasts; cyclic deviations, which
deteriorate during menstruation. Mobile, tender, dominant
lumps, Bilateral nodularity
PLAN
Labs and imagining studies:
US breast left, Mammogram Diagnostic Digital Bilat
Continuation with OB doctor as planned, the performance of
ultrasound in the period of diagnosis and cancer.
Medications, immunizations therapies:
If mastitis will be observed, consume dicloxacillin 500mg PO
QID antibiotics.
Education:
· Train the patient on how to do a breast self-exam.
· Call hospital is presence any fluid or augmented breast pain in
nipple.
· Follow up and referrals
Reference
Mertins, P., Mani, D. R., Ruggles, K. V., Gillette, M. A.,
Clauser, K. R., Wang, P., ... & Kawaler, E. (2016).
Proteogenomics connects somatic mutations to signalling in
breast cancer. Nature, 534(7605), 55-62.