NR602 week 4 soap note

Kayla, 38-year-old Caucasian and Latino female

Subjective

Chief
complaint:complaining of fatigue,
right breast pain, and vaginal itching.

HPI: Thebreast pain is in the right breast
and now into the right axilla. It is warm and tender to touch. She has not
noticed any nipple discharge. She has also had mild myalgia. The vaginal
itching began a few days before the breast pain. She reports a great deal of
stress. She has not been monitoring for a fever. She denies diarrhea or
constipation, abdominal pain, skin changes, cough, or chest pain. She has not
had dysuria. LNMP was 6 weeks ago, 8 days in length, heavy for 5 days with
clots. Menses are irregular, having only 5 to 6 per year.

Past Medical
History -Kayla denies any surgeries or past medical history other than four
pregnancies, three births, one pre-term, and two cesarean sections with the
last two births. She had one miscarriage at 10 weeks when she was 16. She also
reports that she had PCOS as a teenager and has always had irregular menses.
She had gestational diabetes with the last birth.

Family
History-Family History: Her
paternal great grandmother died of breast cancer at the age of 50.Mary
has a history of hyperlipidemia, Type 2 DM, and Hypertension. Tom has a history
of hypertension, hyperlipidemia, and an MI with stenting 2 years ago. The
mother has two siblings; one who died in an MVA 5 years ago at the age of 18 a
younger brother, and an older sister who is 42 and lives in a large urban city
in the Midwest with her family, and she is in good health but also had PCOS and
difficulty conceiving. Other family members died of old age.

Social
History-15-year smoker of 1 PPD up until 18 months ago when she quit with the
pregnancy of Riley. She is concerned about finances today and reports ongoing
fatigue. Not currently sexually active, abstinent for the last 6 months. Does
not exercise, drinks wine frequently, often skips breakfast and lunch and eats
whatever the children eat for dinner often processed or quick food.She continues to live
with her parents during a separation from her husband and is working part time
at the children’s school library but has not been there for over a week. She
has no health insurance, but her children are now covered by the State Medicaid
HMO.

Vital Signs: height: 155
centimeters weight: 71 kilograms BMI 29.6 overweight, B/P:120/62, T: 99.2, HR:
90, Resp: 16, reg, non-labored, SpO2: 99%

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