SOAP Note and Differential Diagnoses for iHuman Case

155 pounds

Name: Carolyn Cross
Age: 41 years
Sex: F
Height: 5′ 3″
Weight: 155 pounds (BMI 275)

Temperature: 984 F (oral)
Pulse: 76 bpm – regular
Blood pressure: 134/74 mmHg122/72 upon standing
Respiratory rate: 16 bpm
SpO2: 98% on room air

Carolyn Cross

Chief complaint:
Well-woman evaluation

SOAP Note and Differential Diagnoses for iHuman Case

Use this week’s iHuman case titled “Carolyn Cross V2VE” and create a SOAP note with a treatment plan (located at the bottom of the SOAP note

Provide a subjective, objective, assessment, and plan (SOAP) note on this patient and your treatment plan using the SOAP note template provided Remember to keep the patient’s identity private; use the minimal amount of information possible to get the idea across
Provide a reference for your treatment plan (in APA format) The reference may come from a journal, a book, etc
Cite all sources using APA format
Include three differential diagnoses and support your diagnoses with supporting literature
Skin:

Warm, dry

Ms Cross is a healthy 41-year-old G2P2 Hispanic-American female who presents for a well-woman examination She has no active medical complaints, but is concerned about her risk of breast cancer as both her mother (age 63) and maternal first cousin (age 44) have been recently diagnosed with intraductal breast cancer Additional risk factors include menarche age 105; first pregnancy age 33; she breast fed each of her two infants for only four months each The patient, reports a normal baseline mammogram at age 40, (report not available) and a history of fibrocystic breast disease She is overweight (BMI 275) with a FH of hypertension, hyperlipidemia (father) and type 2 diabetes (mother)

She is concerned about her risk for breast cancer and does this fact increase her risk of breast cancer, her mother at 63 years old and first cousin 44 year old was recently diagnosed with breast cancer She performs self-breast examines, no lumps or bumps or discharged noted by patient She reports breast tenderness around her menstrual cycle Denies any health problems past or present Immunizations are up to date She gardens and does house work for exercise She reports later she takes vitamin E for fibro cystic breast disease, she had a mammogram 18 months ago Father has hyperlipidemia and HTN and mother is a type 2 DM and just diagnosed at 63 with breast cancer Pt has a glass of wine every night with supper her diet is traditional Hispanic diet Both breast is irregular lump and bump bilateral with slight diffuse tenderness She has two boys and a husband no reported siblings

labs

Name

Value

Units

Reference Range

Cholesterol

239

mg/dL

low risk 239

High-density lipoprotein (HDL)

45

mg/dL

maj risk 59

Low-density lipoprotein (LDL)

159

units/L

low risk 159

Triglycerides

40

mg/dL

(?) 35-135, (?) 40-16

Name

Value

Units

Reference Range

Glucose, 8 hour fasting

122

mg/dL

Name

Value

Units

Reference Range

Hemoglobin A1c

64

%

normal 4-56, elevated risk 57-64, diabetes >67

Her papsmear was normal

The Correct Answer and Explanation is :

SOAP Note for Carolyn Cross

Subjective:
Carolyn Cross, a 41-year-old Hispanic-American female, presents for a well-woman exam. She has no current complaints but is concerned about her risk of breast cancer, given her family history. Her mother (age 63) and maternal first cousin (age 44) were recently diagnosed with intraductal breast cancer. She reports breast tenderness around her menstrual cycle but no lumps or discharge. She has a history of fibrocystic breast disease and received a normal mammogram at age 40 (report unavailable). She denies any other significant health concerns but mentions a family history of hypertension, hyperlipidemia, and type 2 diabetes. Her lifestyle includes light physical activity through gardening and housework, and she consumes one glass of wine nightly with supper. She takes vitamin E for fibrocystic breast disease. Her diet is traditional Hispanic, and she has two children and a husband.

Objective:

• Temperature: 98.4°F (oral)
• Pulse: 76 bpm, regular
• Blood Pressure: 134/74 mmHg sitting, 122/72 mmHg standing
• Respiratory Rate: 16 bpm
• SpO2: 98% on room air
• Skin: Warm and dry
• BMI: 27.5 (overweight)
• Cholesterol: 239 mg/dL (borderline high)
• HDL: 45 mg/dL (borderline low)
• LDL: 159 mg/dL (borderline high)
• Triglycerides: 40 mg/dL (low normal)
• Fasting Glucose: 122 mg/dL (pre-diabetes range)
• Hemoglobin A1c: 6.4% (pre-diabetes range)
• Pap Smear: Normal

Assessment:

1. Breast Cancer Risk: Given her family history (mother and cousin diagnosed with intraductal breast cancer) and personal history of fibrocystic breast disease, Ms. Cross is at an elevated risk for breast cancer. Despite performing regular self-breast exams with no findings, her family history and age at first pregnancy (33 years) raise concern.
2. Pre-diabetes: Ms. Cross’ fasting glucose (122 mg/dL) and Hemoglobin A1c (6.4%) indicate a pre-diabetic state. Her family history of type 2 diabetes and current overweight status contribute to this risk.
3. Dyslipidemia: Her cholesterol levels (total cholesterol: 239 mg/dL, LDL: 159 mg/dL) and low HDL (45 mg/dL) suggest an increased risk for cardiovascular disease. Her father’s history of hyperlipidemia supports this assessment.
4. Overweight: BMI of 27.5 places her in the overweight category, which is a risk factor for multiple conditions, including cardiovascular disease, diabetes, and breast cancer.

Plan:

1. Breast Cancer Screening:

• Recommend annual clinical breast exams and continue self-breast exams.
• Discuss the possibility of earlier mammography due to her family history; consider referring for genetic counseling to assess the risk of hereditary breast cancer syndromes (e.g., BRCA mutations).
• Educate on lifestyle changes to reduce cancer risk, such as weight management and reducing alcohol intake.

1. Pre-diabetes Management:

• Encourage dietary changes to include more fruits, vegetables, whole grains, and lean proteins while reducing processed foods and sugars.
• Recommend at least 150 minutes of moderate-intensity physical activity weekly (e.g., walking, gardening).
• Follow-up in 3-6 months for repeat glucose and A1c testing.

1. Dyslipidemia Management:

• Recommend dietary changes to reduce saturated fats and increase fiber intake (e.g., adding more omega-3 fatty acids, such as in fish or flax seeds).
• Consider statin therapy based on further evaluation of cardiovascular risk, including an assessment of her overall risk using tools like the ASCVD risk calculator.

1. Weight Management:

• Recommend working with a nutritionist or dietitian to create a weight loss plan that aligns with her health goals.
• Encourage daily physical activity, with an emphasis on activities she enjoys (gardening, light housework).

References:
American Diabetes Association. (2023). 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2023. Diabetes Care, 46(Supplement 1), S19-S29. https://doi.org/10.2337/dc23-S002

American Cancer Society. (2023). Breast Cancer Risk and Prevention. https://www.cancer.org/breast-cancer-risk