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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.

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1) Identifying Data:

Patient: John Smith Age: 65 Sex: Male Race: Caucasian Marital Status: Married

Subjective Data:

Chief Complaint: "Blurry vision and difficulty seeing at night."

Subjective Data (HPI):

John reports a gradual decline in his vision over the past year. He describes his vision as blurry, particularly in his left eye. He has also noticed increased difficulty seeing in dimly lit environments and at night. John states that he frequently needs to change his glasses prescription due to worsening vision. He denies any eye pain, redness, or discharge. He has no history of eye trauma. John is concerned that his vision impairment is affecting his daily activities and quality of life.

Review of Systems (associated systems):

Eyes: Blurry vision, difficulty seeing at night, frequent changes in glasses prescription.

Pain: No eye pain reported.

Redness: No eye redness reported.

Discharge: No abnormal eye discharge.

Headache: No headaches associated with visual changes.

Photophobia: No sensitivity to light reported.

PMH, Family Hx, Social Hx, Allergies, Medications:

PMH: Hypertension, hyperlipidemia.

Family Hx: No family history of cataracts.

Social Hx: Retired, non-smoker, occasional alcohol use.

Allergies: No known allergies.

Medications: Amlodipine 5mg once daily for hypertension, Atorvastatin 20mg once daily for hyperlipidemia.

Objective Data:

Vital Signs:

Height: 175 cm

Weight: 78 kg

Blood Pressure: 130/80 mmHg

Heart Rate: 72 bpm

Respiratory Rate: 16 bpm

Temperature: 36.8°C (oral)

Physical Examination:

Eyes: Visual acuity testing reveals decreased visual acuity in both eyes, more pronounced in the left eye. Pupils are equal and reactive to light. Extraocular movements are intact. Slit lamp examination shows bilateral opacities in the lens consistent with cataracts. No signs of inflammation or other abnormalities noted in the anterior segment. Fundoscopic examination reveals a clear view of the posterior segment with no abnormalities detected.

Other Systems: No abnormalities detected during the examination of other systems.

Assessment:

1. Bilateral Cataracts: Based on the patient's subjective complaint of blurry vision, difficulty seeing at night, frequent changes in glasses prescription, and objective findings of bilateral lens opacities consistent with cataracts, the diagnosis of bilateral cataracts is made.

Plan:

Ophthalmology Referral: Refer the patient to an ophthalmologist for further evaluation and management of cataracts.

Education and Counseling: Provide information about cataracts, including their progression and available treatment options, such as cataract surgery.

Visual Aid and Lighting Recommendations: Advise the patient on optimizing vision with the use of appropriate glasses, magnifiers, and adequate lighting in daily activities.

Regular Follow-up: Schedule regular follow-up visits to monitor the progression of cataracts and discuss the need for surgical intervention when appropriate.

Management of Coexisting Conditions: Continue management of hypertension and hyperlipidemia as per current treatment guidelines.

Patient Support: Offer emotional support and address any concerns or questions the patient may have regarding his vision and cataract management.

Subjective/Objective, Assessment, and Management Consistency:

The subjective data provided by the patient regarding blurry vision, difficulty seeing at night, and frequent changes in glasses prescription aligns with the objective findings of decreased visual acuity and bilateral lens opacities consistent with cataracts. The assessment of bilateral cataracts is supported by both the subjective complaints and objective examination. The management plan includes appropriate referral to an ophthalmologist, education, counseling, visual aids, and regular 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, ensuring a complete and accurate representation of the patient's condition.

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