Carolyn Cross V2VE Case Study – SOAP Note and Differential Diagnoses for iHuman Case
Carolyn Cross V2VE Case Study – SOAP Note and Differential Diagnoses for iHuman Case
Name: Carolyn Cross Age: 41 years Sex: F Height: 5′ 3″ Weight: 155 pounds (BMI 27.5) Temperature: 98.4 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.
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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. Carolyn Cross V2VE Case Study – SOAP Note and Differential Diagnoses for iHuman Case.
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. Carolyn Cross V2VE Case Study – SOAP Note and Differential Diagnoses for iHuman Case.
Additional risk factors include menarche age 10.5; 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 27.5) 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. Carolyn Cross V2VE Case Study – SOAP Note and Differential Diagnoses for iHuman Case.
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 <200, moderate 200-239, high >239 High-density lipoprotein (HDL) 45 mg/dL maj risk <40, neg risk >59 Low-density lipoprotein (LDL) 159 units/L low risk <130, moderate 130-159, high >159 Triglycerides 40 mg/dL (?) 35-135, (?) 40-16 Name Value Units Reference Range Glucose, 8 hour fasting 122 mg/dL <126 Name Value Units Reference Range Hemoglobin A1c 6.4 % normal 4-5.6, elevated risk 5.7-6.4, diabetes >6.7 Her papsmear was normal. Carolyn Cross V2VE Case Study – SOAP Note and Differential Diagnoses for iHuman Case.