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SOAP Note format….please see example in attachments
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, 2 differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals and other team members needed to complete patient care.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
Julia is a 37-year-old woman G2P2 who presents with a lump in her left breast. Her husband noticed it recently and she is concerned, because her aunt had breast cancer and she thinks that a great-grandmother or some other ancestor may have died of breast cancer as well. Both of her children, who are ages 9 and 7, were delivered without complications and she breastfed “for well over a year” with each. She has no other significant PMH or allergies. She is 5’ 6” tall, weighs 144 pounds, and has a BMI of 22. Julia works as an office manager. She is a non-smoker, considers herself to be a “meat lover,” and drinks 2 to 3 glasses of wine most evenings with dinner. Her last physical exam was over 10 years ago. Upon examination, a lump is discovered. It is firm and near the surface and no other masses are discovered. The lump is aspirated and an opaque liquid is removed. Following this procedure, the lump vanishes.
What is Julia’s risk of developing breast cancer?
What recommendations, preventative measures, and patient education would you discuss with this patient?
