NR 602 Week 4 Soap Note: Kayla Case

NR 602 Week 4 Soap Note: Kayla Case

NR 602 Week 4 Soap Note: Kayla Case

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.

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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%