NRNP 6568 Week 9 Assignment; Diagnosing, and Treating Special Populations
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Focused SOAP Note
Patient Information: M.S., 28, F, Caucasian S.
CC: Nipple drainage
HPI: This 28 y/o Caucasian female presents with c/o nipple drainage. Patient reports onset of bilateral nipple discharge in the last 3-4 months. Describes discharge as milky and occurring on the left side more than the right and is daily. Patient admits discharge does soak through her bra but does not leak through her outer clothing. Denies odor to discharge and denies erythema, tenderness or lumps to breasts. Patient expresses concern with having cancer.
Patient reports associated symptoms of fatigue, constipation and changes in menses. Patient reports concern with menstrual periods recently becoming light when they have always been moderately heavy. Patient states onset of menses at age 13 and lasts about 5-7 days with heavy bleeding and moderate cramping for the first 3-4 days. Patient admits to use of 8-10 pads each day during the first 3-4 days of her periods. LMP 6/28/21.
Patient reports increased fatigue over last 3-4 months. Patient does admit has battled with fatigue her whole life and has been told she does become anemic during her menstrual cycles and has been instructed to take iron tablets but she refuses this because it upset her stomach. Patient reports having regular stools at least once other day, with stools being soft and formed; however, she reports recent decrease in stools. Reports pattern has changed to a stool about once a week, but remains soft, formed and easy to pass.
Location: Bilateral breasts Onset: 3-4 months Character: Milky
Associated signs and symptoms: Light periods, fatigue and constipation Timing: daily
Exacerbating/relieving factors: Compression or stimulation of the breasts increases discharge. Nothing relieves the discharge.
Severity: 0/10
Current Medications: No prescription medications. No over-the-counter medications. No vitamins or herbals.
Allergies: No known medication, environmental, food, or latex allergies.
PMHx: Received all immunizations as a child. Influenza vaccine 09/2020. Moderna COVID-19 vaccine #1- 4/21/2021, #2- 5/19/21. Patient reports has never been diagnosed with COVID but has been exposed. No hospitalizations, injuries or trauma. No blood transfusions............. Continue
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