NR602 week 4 soap note – Kayla, 38-year-old Caucasian and Latino female

NR602 week 4 soap note – 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%. NR602 week 4 soap note – Kayla, 38-year-old Caucasian and Latino female.

NR602 Week 4 SOAP Note – Kayla, 38-year-old Caucasian and Latino Female

Subjective

Chief Complaint: Kayla is complaining of fatigue, right breast pain, and vaginal itching.

History of Present Illness (HPI): The breast pain is localized to the right breast and extends into the right axilla. The area is warm and tender to touch. No nipple discharge is noted. Additionally, Kayla has experienced mild myalgia. The onset of vaginal itching preceded the breast pain by a few days. Kayla reports experiencing a significant amount of stress. She has not been monitoring for fever. Denies any symptoms of diarrhea, constipation, abdominal pain, skin changes, cough, or chest pain. No dysuria is reported. Last normal menstrual period (LNMP) occurred 6 weeks ago and lasted for 8 days, with heavy flow for 5 days accompanied by clots. Menstrual cycles are irregular, occurring only 5 to 6 times per year.

Past Medical History: Aside from four pregnancies (three births, one pre-term, and two cesarean sections with the last two births), Kayla denies any surgeries or significant medical history. She experienced a miscarriage at 10 weeks of gestation when she was 16. Kayla had polycystic ovary syndrome (PCOS) as a teenager, leading to irregular menstrual cycles. She had gestational diabetes during her last pregnancy.

Family History: Paternal great grandmother passed away from breast cancer at age 50. Family members Mary, Tom, and her mother have a history of hyperlipidemia, Type 2 diabetes, and hypertension. Mother has two siblings, one of whom died in a motor vehicle accident 5 years ago at age 18. Kayla’s younger brother and older sister (42 years old) are in good health. The sister had PCOS and fertility challenges. Other family members had deaths related to old age.

Social History: Kayla was a 15-year smoker, consuming 1 pack per day until she quit 18 months ago during her pregnancy with Riley. She expresses financial concerns and reports persistent fatigue. Currently not sexually active, abstinent for 6 months. Minimal physical activity, frequent consumption of wine, irregular eating habits including skipping breakfast and lunch, and relying on processed or quick foods for dinner (often the same as her children’s). Currently living with her parents due to marital separation. Works part-time at her children’s school library but has not been present for over a week. Lacks health insurance, while her children are covered by State Medicaid HMO.

Vital Signs:
– Height: 155 centimeters
– Weight: 71 kilograms
– BMI: 29.6 (overweight)
– Blood Pressure: 120/62 mmHg
– Temperature: 99.2°F
– Heart Rate: 90 beats per minute
– Respiratory Rate: 16 breaths per minute, regular and non-labored
– Oxygen Saturation (SpO2): 99%