SOAP Note Example: Breast Cancer
1) Identifying Data:
Patient: Mary Johnson Age: 48 Sex: Female Race: Caucasian Marital Status: Married
Subjective Data:
Chief Complaint: "Lump in my right breast and nipple discharge."
Subjective Data (HPI):
Mary reports discovering a palpable lump in her right breast three weeks ago. The lump is located in the upper outer quadrant and is associated with occasional tenderness. She also noticed a clear nipple discharge from the affected breast. The lump has been gradually increasing in size, and she has experienced mild discomfort in the breast. She denies any recent trauma or injury to the breast. Mary is concerned about the possibility of breast cancer due to a family history of the disease.
Review of Systems (associated systems):
Breasts: Presence of a palpable lump in the right breast.
Skin: No skin changes, dimpling, or nipple retraction observed.
Nipple: Clear nipple discharge noted from the right breast.
Pain: Mild discomfort reported in the affected breast.
Lymph Nodes: No enlarged lymph nodes in the axillary or supraclavicular regions.
Weight Loss: No significant weight loss.
Fatigue: Mild fatigue reported but attributed to increased anxiety.
Respiratory: No respiratory symptoms reported.
Gastrointestinal: No gastrointestinal symptoms reported.
PMH, Family Hx, Social Hx, Allergies, Medications:
PMH: No significant medical history.
Family Hx: Family history of breast cancer in the patient's maternal aunt.
Social Hx: Mary is a non-smoker, works as a teacher, and leads an active lifestyle.
Allergies: No known allergies.
Medications: Currently not taking any medications.
Objective Data: Vital Signs:
Height: 165 cm
Weight: 68 kg
Blood Pressure: 120/80 mmHg
Heart Rate: 76 bpm
Respiratory Rate: 14 bpm
Temperature: 36.7°C (oral)
Physical Examination:
General Appearance: Alert, oriented, and cooperative.
Breasts: Inspection reveals a visible asymmetry between the right and left breasts. Right breast palpation reveals a firm, non-mobile lump measuring approximately 2 cm in diameter in the upper outer quadrant. The skin overlying the lump appears normal. No nipple retraction or discharge observed on examination. Left breast appears normal.
Axillae: No enlarged lymph nodes palpated in the axillary regions bilaterally.
Lungs: Clear breath sounds bilaterally.
Cardiovascular: Regular rate and rhythm, no murmurs or abnormal sounds.
Assessment:
1. Breast Cancer, Suspicious for Malignancy: Based on the patient's complaint of a palpable lump in the right breast, associated nipple discharge, and family history of breast cancer, the diagnosis of suspicious breast cancer is made. Further evaluation and diagnostic testing are warranted.
Plan:
Diagnostic Imaging: Schedule a mammogram and ultrasound of the right breast to assess the characteristics of the lump and evaluate the presence of any additional abnormalities.
Breast Biopsy: Consider a core needle biopsy or surgical excisional biopsy of the palpable breast lump to obtain tissue for histopathological examination and definitive diagnosis.
Referral to Breast Surgeon: Refer the patient to a breast surgeon for further evaluation, consultation, and discussion of treatment options.
Genetic Counseling and Testing: Discuss the possibility of genetic counseling and testing, considering the patient's family history of breast cancer.
Psychosocial Support: Provide emotional support, counseling, and education regarding breast cancer, including available resources and support groups.
Follow-up: Schedule a follow-up appointment to review the results of the diagnostic tests and discuss further management options based on the biopsy findings.
Subjective/Objective, Assessment, and Management Consistency:
The subjective data provided by the patient regarding the presence of a palpable lump in the right breast, associated nipple discharge, and family history of breast cancer aligns with the objective findings of a firm, non-mobile lump in the upper outer quadrant of the right breast. The assessment of suspicious breast cancer is consistent with the subjective and objective data presented. The management plan includes appropriate diagnostic tests, referral to a specialist, genetic counseling consideration, psychosocial support, and follow-up.
Clarity of the Write-up:
The SOAP note is written in a clear, organized, and detailed manner, providing comprehensive information regarding the patient's identifying data, subjective and objective data, assessment, and management plan. The note adheres to the specified format and addresses each component thoroughly.
SOAP note For Asthma
Mastering the Art of Writing SOAP Notes
SOAP note For Alzheimer disease
soap note example autism spectrum disorder






