- Change “strange symptoms” and use the term that the patient used in stating her problem. Note the amount and consistency of the blood and if how many times she changed pantyliners in one day, if its soaked or not.
- 1/10 is a pain scale, if there is no pain do not use the scale and instead state that she don’t feel any pain
- I got confused if weight loss is related to her symptoms or diet
- HPI means history of present illness, previous illnesses should be on the past health history
- Change the statement for the negative papsmear result to “but the patient claimed that she has positive result.”
OLDCART” which stands for Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors/Radiation and Treatment
- Character- should describe the blood/spotting
- Aggravating factors- for ex.if the bleeding happens after sexual intercourse, during activity etc
- Relieving factors- does not stop with any remedy
Medications -state how long she is taking the drug and if she’s compliant with her prescriptions
Hospitalizations-rearrange it according to dates, first is when she was 8
Family history-state cause of death of the parents and you stated the age of her siblings twice
- occupation is kinda confusing, state the job that she retired on.
- how many times is a frequent visit? 2-3x a week?once? Pls indicate
General- is wt loss sudden?
General- Appears alert?
Skin – pls describe the color of skin not the race, is the skin cold?warm to touch?
HEENT- describe the color of sclera
GI-what do you mean by the abdomen is obese? Pls describe using appropriate medical terms
Breast-I’m sorry i did not understand what you meant by breast is selling and palpable axillary lymph?
Musculoskeletal- i think you no longer need to state that you observed the rom on waiting area?
Neuro – are you not required to take the reflexes such as tendon reflex, etc?
Running head: SOAP 2
Name Ram Pandey
Professor: Dr.Regina Germonprez
Class: NSG 6430
Date of submission September 25, 2020
Name: AP Age: 52 Sex: F Date: 11/09/2019 Time: 1700hrs
AP, a 52-year-old woman, came to the hospital and complained of several signs. These included reddening of the nipple, breast discharge, which was not breast milk and had bloodstains, lump swell at the edge of the breast near the armpit, and general swelling and discomfort. She said that at first, the symptoms looked normal since it was only itching of the nipple, so she did not undergo any medication. She admitted that symptoms continued to worsen with pain in the chest, neck, and back pains which caused everyday fatigue, nausea, and lack of appetite. She had not undergone any lab tests and had only been under pain relievers.
Mammogram and ultrasound tests were conducted since her condition seemed to worsen to see any cancer cells. It was confirmed that the patient had breast cancer, and two procedures were conducted. These were chemotherapy and radiation therapy. In chemotherapy, drugs were inducted into the veins of the patient near the chest, which lasted an hour. The procedure was done to kill rapidly growing cells within the breast.
Radiation was done after lumpectomy, which was the removal of the swollen lump. This was done to prevent the risk of breast cancer recurrence in the affected breast.
Another medical history
Never had any health complications related to breast cancer. From the record, the only case was flue infection, and the condition was treated without causing any threat to the health status of the patient.
Said mother had health complications and not alive. The father had no cancer complication although he passed own. In their family, there are two ladies and one man. All the ladies had breast cancer complications meaning that the disease had passed from the mother to the offspring through genetic transfer.
She is married to one partner, and they live together. He w
Name: Date: Time:
Reason given by the patient for seeking medical care “in quotes”
Describe the course of the patient’s illness, including when it began, character of symptoms, location
where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other
related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
Medications: (list with reason for med )
PMH (include – immunization status including Gardisil, GTPLA)
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries (include delivery of pregnancies here)
“Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart
disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”
Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with:
lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
Education level, occupational history, current living situation/partner/marital status, substance use/abuse,
ETOH, tobacco, marijuana. Safety status ADD VAPING
ROS (if you are seeing a patient for an Episodic OV – you may alter the ROS accordingly)
Weight change, fatigue, fever, chills, night sweats,
Chest pain, palpitations, PND, orthopnea, edema
Delayed healing, rashes, bruising, bleeding or skin
discolorations, any changes in lesions or moles
Cough, wheezing, hemoptysis, dyspnea, pneumonia
Corrective lenses, blurring, visual changes of any
Abdominal pain, N/V/D, constipation, hepatitis,
hemorrhoids, eating disorders, ulcers, black tarry
Ear pain, hearing loss, ringing in ears, discharge
Urgency, frequency burning, change in color of
Contraception, sexual activity, STDS
Fe: last pap, breast, mammo, menstrual
complaints, vaginal discharge, pregnancy hx (This
should be in the in PMH as well.)
Sinus problems, dysphagia, nose bleeds or
discharge, dental disease, hoarseness, throat pain
Back pain, joint swelling, stiffness or pain, fractu