NR603 Week Five SOAP Note2

SOAP Note: Dawn Fox S.

Patient Information:
  • Name: SM
  • Age: 50
  • Gender: Female
  • Ethnicity: Caucasian
  • Insurance: Unknown
Subjective:
  • Chief Complaint (CC): Patient is concerned about a mole on her neck, and her sister has reported noticing cognitive changes in recent days.
  • History of Present Illness (HPI):
    • Onset: Unknown
    • Location: Mole on the neck
    • Duration: Unknown
    • Characteristics: 8mm mole with an extended border, black or purple in color, and slightly raised.
    • Aggravating Factors: None
    • Relieving Factors: None
    • Treatment: None
  • Current Medications:
    • Black Cohosh
  • Allergies:
    • Sulfa Drugs (causes hives)
  • Past Medical History (PMHx):
    • Overall health is good
    • Tdap vaccine in 2000
    • Declines flu vaccine
    • No past surgeries, no adult illness, no previous hospitalizations
    • Chickenpox as a child
    • No blood transfusions
  • Social History (SocHx):
    • Divorced 15 years ago
    • Two children, ages 24 and 22
    • Works as a gardener
    • Does not exercise regularly
    • Does not drink alcohol or use illicit drugs
    • Sleeps between 10-12 hours per night
  • Family History (FamHx):
    • Parents are living, both have hypertension (HTN)
    • Mother has diabetes and Parkinson’s disease
    • Two siblings with hypertension and atrial fibrillation
    • Both her children are healthy
  • Review of Systems (ROS):
    • Constitutional: No fever, chills, or fatigue
    • HEENT: Denies changes in vision, no hearing loss, change in taste or smell
    • Skin: Denies any skin breakdown, sores, bleeding, or non-healing wounds
    • Cardiovascular: Denies chest pain or palpitations
    • Pulmonary: Denies shortness of breath
    • Neurological: Denies weakness, dizziness, trouble with speech, chewing, or balance
    • Neurocognitive: Denies trouble with directions, memory, or completing simple tasks
    • Allergies: No history of asthma or skin irritations
Objective:
  • Height: 5'10"
  • Weight: 200 lbs
  • BMI: 28.7 (Overweight)
  • Vital Signs:
    • Blood Pressure: 130/67 mmHg
    • Temperature: 98.7°F
    • Pulse: 75 bpm
    • Respiratory Rate: 18 breaths/min
  • Physical Exam (PE):
    • General Appearance: White female, appears stated age, no acute distress (NAD), alert to situation
    • Skin: 8mm mole on the neck with extended borders, black/purple in color, slightly raised, no bleeding, no surrounding erythema
    • Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops; peripheral pulses intact
    • Respiratory: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi
    • Neurological: Alert and oriented to person, place, time, and situation; cranial nerves II-XII grossly intact; no focal deficits noted
Assessment:
  1. Suspicious Mole/Neoplasm of Uncertain Behavior (D48.5):
    • The mole’s characteristics—8mm in size, irregular border, and dark coloration—are concerning for potential melanoma. Given the patient’s fair skin and family history of melanoma, further evaluation is warranted.
  2. Mild Hypertension (I10):
    • BP 130/67 indicates borderline/mild hypertension. Although currently not treated, it’s important to monitor and manage through lifestyle modifications due to family history.
  3. Possible Cognitive Changes (R41.3):
    • Although the patient denies cognitive difficulties, the sister’s report of recent changes warrants a closer assessment, possibly including neuropsychological testing.
Plan:
  1. Mole Evaluation:
    • Referral to Dermatology: Immediate referral for biopsy to rule out melanoma.
    • Patient Education: Advise the patient on the ABCDEs (Asymmetry, Border, Color, Diameter, Evolving) of melanoma and the importance of regular skin checks.
    • Follow-Up: Schedule a follow-up visit in 1 week to discuss biopsy results and further management.
  2. Hypertension Management:
    • Lifestyle Modifications: Encourage regular exercise, a low-sodium diet, weight management, and stress reduction techniques.
    • Monitoring: Recheck blood pressure at the next visit.
    • Patient Education: Discuss the importance of controlling blood pressure to prevent cardiovascular complications.
  3. Cognitive Function:
    • Further Assessment: Consider neuropsychological testing or Mini-Mental State Examination (MMSE) at the next visit if cognitive changes persist or worsen.
    • Patient and Family Education: Discuss the early signs of cognitive impairment and the importance of monitoring changes in memory and function.
  4. Health Maintenance:
    • Vaccinations: Strongly recommend an annual flu vaccine, given the patient’s overall health status.
    • Patient Education: Discuss the benefits of vaccination, especially for preventing complications from flu-related illnesses.