Annotated Soap Note Assignment Example | Topics and Well Written Essays - 750 words

Annotated Soap Note - Assignment ExampleThe pain does not extend to other areas and the pack is located close to the nipple and feels sullen when touched. The lump emerged about three weeks ago. The patients report no transform in the size of the breast and there is no discharge.Pertinent medical immunizations up to date (last TD Jan 2015). She has undergone state of affairs mastectomy radiation therapy six months, 20mg/day tamoxifen, and 600mg ibuferon. The patient denies ever using hormonal drugs.Family history Her mother passed aside due to breast cancer at the age of 65 years. The father living (70-year-old) has history of high blood pressure and DM. has two siblings (brother 35 years old and sister 37 year old) both in computable health.Social history She admits smoking three to five cigarettes a day but denies using hard drugs and alcohol. The patient is single and has no children. She is an active dancer and participates in swimming. Her current diet is low large calor ie with a lot of fruits and vegetables.General Presents in a normal state of good weight and health. No recent weight loss or gain. No presence of rash around the nipple of the left field breast. There is pain on the lump when pressed. No lumps on the armpit.HEENT no problem with hearing or vision. No headaches or dizziness. Normal nasal diameters, and no running nose or congestion. There is no evidence of removable or permanent dental. Last dental assessment conducted on January 2015.The lump is smooth, elastic and moves with ease within the breast weave. A fine needle aspiration was conducted to obtain a tissue for testing. There is no bleeding or discharge from the nipple and neither is there either variegate in color.The diagnosis is based on three assessments imaging, cytopathological and clinical. The three assessments aim to reduce the effect of any technique of diagnosis being less than 100% specific and sensitive to diagnose or kill breast cancer. The clinical assessme nt aim to