SOAP Note
Patient’s Details
Initials: D.P. Age: 38 years Race: White Gender: Female
SUBJECTIVE:
Chief Complaint (CC): “The nipple of my right breast is painful, itchy, scaly, and red. I also feel a burning sensation in the nipple area.”
History of Present Illness (HPI): D.P., a 38-year-old white woman with two children with last menstrual period occurring two weeks ago has reported to the clinic complaining of pain, itchiness, redness, and a burning sensation in the right nipple. These symptoms started a week ago. D.P. also reports that the skin covering the nipple is scaly and is ulcerated.
The nipple bleeds quite often due to constant scratching. The itchiness and pain are persistent and they occur almost all the time. Further reports indicate that the pain and itchiness are so severe that they affect the patient’s ability to concentrate in other activities. D.P. denies nausea, fatigue, and vaginal bleeding.
Medications: Does not use any medications at the moment.
Allergies: Denied both drug-related and food-related allergies.
Menstrual history: Menarche was at 13 years. Menstrual cycle is 28 days and menses last for 4 days with minimal cramping. Her last menstrual period was two weeks ago on 7th October, 2021.
Gynecologic history: Denies a history of breast disease. D.P. has never obtained a breast exam before.
Contraceptive/sexual history: Denies use of hormonal contraceptives. She is sexually active and reports the use of condom with partner as means of contraception.
PMH: Childhood diseases as per available medical records were measles, chicken pox, and pneumonia. D.P. denies being diagnosed with any serious medical condition during adulthood.
Social History: The patient is currently married with two children; a girl and a boy aged 18 and 15 years respectively. Her husband is 44 years old. D.P. is currently employed as a secretary in a nearby coffee factory. She denies consuming alcohol or cigarettes.
Family History: Father is 67 years old and does not have any underlying medical conditions. Mother is 60 years and was diagnosed with breast cancer 2 years ago. Her husband and their two children are healthy.
Review of Systems (ROS)
General: Denies abnormal weight gain or weight loss, denies body weakness, fatigue, or fever. Denies nausea and vomiting.
Skin: Denies skin rashes, skin erythema, or abnormal changes in skin color. No changes in nail structure and appearance reported.
HEENT:
Head: Denies headache or head trauma/injury.
Eyes: Does not report issues with vision, pain in the eyes, or excessive tearing. Does not use glasses/contact lens.
Ears: Denies hearing loss. Does not report changes in hearing or ringing in ears. Denies a history of ear infections.
Nose and Sinuses: No frequent colds reported. Denies nasal stuffiness or nosebleeds. No obstruction, pain, or discharge reported. The patient denies sneezing or any challenges while breathing through the nose.
Mouth and throat: Denies mouth ulcers or soreness in the tongue. Does not report hoarseness or soreness in the throat. No issues with teeth or gums reported.
Neck: Denies lumps or swollen lymph nodes in the neck region. The patient further denies goiter or pain on the neck.
Lymphatics: Denies swollen lymph nodes in neck area
Breasts: Does not report lumps in the breasts. Reports pain, bleeding, itchiness, redness, and a burning sensation in the right nipples. The patient further reports that the right nipple is ulcerated and scaly.
Pulmonary: Denies a cough, wheezing, or difficulty breathing. Does not report pain in the chest during inhalation and exhalation.
Cardiovascular: D.P. denies chest pain or dyspnea. Denies shortness of breath, tightness of the chest, or orthopnea. Does not report edema, hypertension, a history of a murmur, or known heart disease. Denies
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