SOAP Notes

S. 30 y/o G0P0 female with Family Hx of breast cancer (maternal aunt was BRCA positive who had breast surgery), and PSHx of benign breast biopsy presents to breast clinic today for follow-up status post abnormal ultrasound breast imaging. Patient denies having any nipple discharge, breast dimpling or breast skin changes. Patient mentions she had menarche at 10 years old. She denies any family history of ovarian or endometrial cancer. Patient admits to using oral contraceptives for over 4 years. Her last menstrual period was roughly 2 weeks ago.

O. Vitals: BP: 117/75 Pulse: 72 Resp: 14 Temp: 98.3F Sp02: 98% on room air

Gen: Female in her 30s is sitting in the clinic; She is awake, alert, and oriented x 3 and in no acute distress.

Skin: Warm with no cyanosis, diaphoresis, or edema

Resp: Normal respiratory effort on room air

Right Breast: Mass present on the 12:00 axis 3 cm from the nipple. No inverted nipple, nipple discharge, skin change or tenderness noted.

Left Breast: No mass, inverted nipple, nipple discharge, skin change or tenderness noted.

No axillary lymphadenopathy present bilaterally.

Imaging:

US Breast Complete Bilateral 3/4/2024

Findings:

Bilateral breast ultrasound

In the right breast at the 12:00 axis 4 cm from the nipple, there is a stable 0.9 cm mass, previously biopsied noted to be a fibroadenoma.

In the right breast 12:00 axis 3 cm from the nipple, there is a new 1.2 cm lobulated heterogeneous mass.

In the right breast at the 11:00 axis 3 cm from the nipple, there is diminution of 1.5 cm mass with clip in place, previously biopsied, fibroadenoma

There are no other suspicious lesions noted on ultrasound of both breasts. There are normal-appearing axillary lymph nodes bilaterally.

Impression:

Ultrasound-guided core biopsy recommended right breast 12:00 axis 3 cm from the nipple. No ultrasound evidence for malignancy on the left.

Recommendation:

Recommend Surgical Consultation for the right breast.

Recommend Ultrasound Core Biopsy for the right breast. Please order an US Core Needle Breast Biopsy Right.

BI-RADS: Overall: 4 – Suspicious

A. 30 y/o female with abnormal breast imaging with recommendation to have a right breast ultrasound core biopsy.

P. Patient has been scheduled for ultrasound guided right breast core biopsy on April 11, 2024. Biopsy instructions were discussed and provided to the patient. A referral for genetic testing was given. Patient was instructed to return to clinic two weeks after her biopsy. Patient was discussed with the attending.

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S. 57 y/o female with PMHx of GERD and PSHx of prior abdominoplasty (done in 2014) presents to the emergency room for right upper quadrant pain, nausea, and non-bilious non-bloody emesis. Patient states pain is very sharp and rates it a 6/10. Patient mentions the pain has been present for 2 days after eating a cheeseburger and fries. This is the second time she has felt this pain, but says that the first time was not this severe. The first time this has happened was about 7 days ago. Patient denies any fevers or chills.

O. Vitals: BP: 150/75 Pulse: 67 Resp: 18 Temp: 97.9F Sp02 99% on room air

Gen: Female in her 50s is lying in the hospital bed; She is awake, alert, and oriented x 3 and in no acute distress.

Skin: Warm with no jaundice, diaphoresis, or edema

HEENT: PERRLA, extra ocular movements intact, no lymphedema noted

Resp: normal respiratory effort on room air

Abd: Non-distended, soft and tender to palpation in the right upper quadrant, no rebounding or guarding has been noted.

Imaging: CT Abdomen and Pelvis with Contrast Exam date and time: 3/26/2024

Findings:

Liver: Unremarkable.

Gallbladder and bile ducts: Several gallstones noted with 18 mm in diameter periphery calcified gallstone in gallbladder neck. Distended gallbladder noted. No significant dilation of the biliary system.

Pancreas: Unremarkable.

Spleen: Unremarkable.

Adrenal glands: Unremarkable.

Kidneys and ureters: No hydronephrosis noted.

Stomach and bowel: No obstruction. No mucosal thickening. Mild colonic diverticulosis.

Appendix: No evidence of appendicitis.

Intraperitoneal space: Trace simple density fluid in cul-de-sac.

Vasculature: Diffuse mild atherosclerotic calcification.

Lymph nodes: No enlarged lymph nodes.

Urinary bladder: Unremarkable as visualized.

Impression: Cholelithiasis extending to gallbladder neck. Distended gallbladder.

Labs: WBC 6.89, Sodium 136, Potassium 4.3, Chloride 100, C02 26, BUN 10, Creatinine 0.86, Calcium 9.4

A. 57 y/o female with acute cholelithiasis, with a stone is visualized in the neck of the gallbladder, with normal WBC and labs.

P. Keep patient NPO. Give her Lactated Ringers with 500 ml bolus and then 125ml/hr for maintenance. Pain control with IV Toradol 30mg once. Nausea control with IV Reglan 10mg once. Admit to surgery floor for surgery. Patient to be discussed with on-call surgeon.

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S. 64 y/o female presents to the general surgery clinic for follow up on her open umbilical hernia repair with mesh and JP drain done on 3/21/2024. Patient has been tolerating a normal diet and drinking fluids, and has been having normal bowel movements (at least once daily) and voiding without issue. Patient denies any fevers, chills, nausea, abdominal pain, or vomiting. Patient mentioned that her JP drain had 10cc of output in the last 24 hours.

O. Vitals: BP: 132/86 Pulse: 83 Resp: 16 Temp: 98.9F Sp02: 98% on room air

Gen: Female in her 60s is sitting in the clinic; She is awake, alert, and oriented x 3 and in no acute distress.

Skin: Warm with no cyanosis, diaphoresis, or edema

Resp: Normal respiratory effort on room air

Abdominal: Midline surgical incision looks clean, dry, and intact with staples with no signs of erythema or necrosis of the skin or any signs of bleeding. JP drain has serosanguinous output.

A. 64 y/o female with open umbilical hernia repair with mesh and JP drain done on 3/21/2024.

P. JP drain was removed entirely. Patient tolerated the removal well. Sutures were removed and steri-strips were placed along the midline incision. Patient was seen with the attending and advised to return to clinic if any issues should arise in the future.

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S. 67 y/o female with PMHx of poly-substance abuse and bilateral upper extremity infection was found on the sidewalk and brought in by EMS due to altered mental status. Due to the altered state the patient is in, more information could not be ascertained from her, as well as a scant medical history that could be found through her medical records.

O. Vitals: BP: 141/70 Pulse: 101 Resp: 28 Temp: 102.6 F Sp02: 99% on room air

Gen: Female in her 60s is laying in the hospital bed; She is lethargic and ill-appearing but not in acute distress. Patient is unable to respond to questions

HENT:

Head: Normocephalic and atraumatic.

Eyes: Pinpoint pupils are seen. No eye discharge or scleral icterus is noted

Nose: No bleeding or erythema seen. No congestion or rhinorrhea noted.

Mouth/Throat: Mucous membranes are dry

Cardiac: Tachycardic with normal rate and rhythm. 2+ radial pulses bilaterally 

Resp: Normal respiratory effort on room air with not adventitious breath sounds heard

Abdominal: Non-distended and soft

Skin: Multiple 1-2cm circular necrotic lesions are seen on patient’s dorsal foreman bilaterally. Pus can be aspirated from some of the lesions. Patient’s skin around the necrotic lesions is erythematous. There is no bleeding noted from any of the lesions.

LABS: WBC 31.90, Sodium 131, Potassium 3.3, Albumin 3.0

A. 67 y/o female with PMHx of poly-substance abuse and bilateral upper extremity infection presents to the emergency room with tachycardia, WBC of 31.9 and a temperature of 102.6 F with bilateral upper extremity tissue infection.

P. Patient will be sent to the operating room tonight for surgical debridement of her bilateral upper extremity soft tissue infection. Keep patient NPO. Give her IV fluids with Lactated Ringers 125 ml/hr for maintenance. Start her on IV Vancomycin for MRSA coverage.

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