Ciara

Need Soap Note in the same format as I have it in the attachment.  Needs to be 100% Plagiarism free.  No excuses on it not from Internet or any University either.  Please check turnit in before submitting it.  

3-4 references as well.  Its on womens Health.

Please see the attached paper.

Thank You

Running head: SOAP 2

Soap notes

Name Ram Pandey

Professor: Dr.Regina Germonprez

Class: NSG 6430

Date of submission September 25, 2020

SOAP NOTES

Name: AP Age: 52 Sex: F Date: 11/09/2019 Time: 1700hrs

subjective

CC:
Breast cancer

AP, a 52-year-old woman, came to the hospital and complained of several signs. These included reddening of the nipple, breast discharge, which was not breast milk and had bloodstains, lump swell at the edge of the breast near the armpit, and general swelling and discomfort. She said that at first, the symptoms looked normal since it was only itching of the nipple, so she did not undergo any medication. She admitted that symptoms continued to worsen with pain in the chest, neck, and back pains which caused everyday fatigue, nausea, and lack of appetite. She had not undergone any lab tests and had only been under pain relievers.

Medication
Mammogram and ultrasound tests were conducted since her condition seemed to worsen to see any cancer cells. It was confirmed that the patient had breast cancer, and two procedures were conducted. These were chemotherapy and radiation therapy. In chemotherapy, drugs were inducted into the veins of the patient near the chest, which lasted an hour. The procedure was done to kill rapidly growing cells within the breast.
Radiation was done after lumpectomy, which was the removal of the swollen lump. This was done to prevent the risk of breast cancer recurrence in the affected breast.

Cysts
Tested negative
Fibroids
Tested negative

Another medical history
Never had any health complications related to breast cancer. From the record, the only case was flue infection, and the condition was treated without causing any threat to the health status of the patient.

Family history
Said mother had health complications and not alive. The father had no cancer complication although he passed own. In their family, there are two ladies and one man. All the ladies had breast cancer complications meaning that the disease had passed from the mother to the offspring through genetic transfer.

Social history
She is married to one partner, and they live together. He works as an institution clerk and is on medication. The partner stays away, and in most cases, she enjoys the company of the neighbour and the workmates. When she is free, she likes traveling, reading novels, and watching movies.

Obstetric history
The patient complained of pain on the breast that was different from the normal functioning of the body. Considering that she was not lactating the child, it was obvious that the problem causing the pain was the growth of cancerous cell on the breast

Health maintenance
To maintain the health status of the body, she has to maintain a healthy weight of the body. The weight of the patient is important in determining how the body responds to the effects of the disease. Therefore, she was advised to maintain her body weight to keep the body fit.
She ensures that vegetables and fruits form part of her diet to boost the immunity of the body. Vegetables and fruits provide the required vitamins in providing the anti-bodies to help the body fight the impact of the disease.
The integration of 100% whole grain as part of the food, such as cereals, provided the necessary energy to enable the body to perform the required activities. Pain affects the operation of the body that requires the body to have adequate energy. Chemotherapy treatment also requires the energy to enable the patient to undergo the whole process successfully.

Review of the System (ROS)

General
She did not show a rapid change in body weight
Body temperature was in normal condition
The appetite was in normal condition
No case of chest pain

Respiratory process
There were no cases of respiratory complications because the breathing process functions normally.

Breast
There exist physical growths on the breast
The shape of the breast was not normal
Existence of hard substance on the breast when pressed just like stones

Throat and mouth
Working in normal condition

Psychiatric
The patient did not have any suicidal attempts
The patient controls anger normally

Genitourinary
The colour of urine is normal
Urine has a normal odor
The patent has no medical record of STDs

Factual

The body weight: 171.96 lbs. height :5.5 ft. Temperature: 98.13 degrees

The heartbeat rate for the respiratory process is 80 beats per minute

Breast
Existence of new lump on the armpit
Swelling of the breast
Discharge on the nipple that includes bloodstains
Existence of flaky breast skin

Psychiatric
She does not feel depressed with the condition of having breast cancer. She stays a better lifestyle eating a balanced diet. Even though the husband is away but when she is stressed, she shares a lot with neighbours and friends to prevent depression, resulting in suicidal thinking.

Genitourinary
The urine produced is a pale yellow colour indicating the normal colour without any discharge that could indicate any virginal infection

Diagnosis
A biopsy was conducted where a medical needle device was used to extract a cell from the suspected area examined by performing the x-ray. The swollen part identified physically by the doctor was subjected to x-ray, and the cells of the affected part were extracted for further tests. The suspected area can be identified through mammogram screening.

Treatment
Two procedures were conducted. These were chemotherapy and radiation therapy. In chemotherapy, drugs were inducted into the veins of the patient near the chest, which lasted an hour. The procedure was done to kill rapidly growing cells within the breast.
Radiation was done after lumpectomy, which was the removal of the swollen lump. This was done to prevent the risk of breast cancer recurrence in the affected breast.

References

Rugo, H. S., Olopade, O. I., DeMichele, A., Yau, C., can’t Veer, L. J., Buxton, M. B., … & Symmans, W. F. (2016). Adaptive randomization of veliparib–carboplatin treatment in breast cancer. New England Journal of Medicine, 375(1), 23-34.

Wang, L. (2017). Early diagnosis of breast cancer. Sensors, 17(7), 1572.

Wein, L., Luen, S. J., Savas, P., Salgado, R., & Loi, S. (2018). Checkpoint blockade in the treatment of breast cancer: current status and future directions. British journal of cancer, 119(1), 4.