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Peer Response Post: Post a response to an original SOAP post that is relevant, evidence-based and supported by current literature. 
SOAP NOTE ATTACHEDPatient Initials: M. G

Pt. Encounter Number:

Date: 10/06/2020

Age: 31

Sex: F

Allergies: NKDA Advanced Directives: NONE

SUBJECTIVE

CC:

Abnormal milky nipple discharge

HPI

31-year-old Hispanic female who c/o milky nipple discharge for the past two weeks accompanied by headache and occasional episodes of dizziness. Both breasts are affected, patient denies menstrual irregularities or any history of substance abuse. LMP was three weeks ago.

Current Medications:

None

PMH

Menstrual History: LMP three weeks ago, age of Menarche 13
OB history: 0
Gynecological history:
Last Pap smear: 2 years ago
Last MMG: Never
No history of miscarriages
General History: None
Surgical History: Denies surgical history
G0P0A0

Family History:

Mother lives, Hypertension. Father lives, suffers from Addison’s disease and Diabetes Mellitus Type 2.

Social History: Patient is single, employed as an elementary school teacher, never smoked, no alcohol or drug use. Exercises regularly. Sexual history: onset of coitus age 18, currently 1 partner, sexually active.

ROS

General: Reports dizziness and weakness. Denies change in appetite, sleep problems. Denies weight change, fatigue, fever, chills, night sweats.

Cardiovascular

Patient denies chest pain/distress, palpitations, dyspnea, orthopnea, edema, hypertension, previous myocardial infarction, past electrocardiogram or cardiac arrest, murmurs, leg edema, capillary refill, varicose veins, distal pulses (radial, brachial, popliteal, posterior tibial, dorsalis pedis) 2 +.

Skin

Patient denies rash or eruptions, itching, pigmentation or texture changes, excessive sweating, unusual nail or hair growth, scars, bruises, rashes, masses, lumps, sores

Respiratory

Patient denies pain related to respiration, dyspnea, cyanosis, wheezing, cough, sputum (color/quantity/smell), hemoptysis, night sweats, exposure to tuberculosis, clubbing of fingers, clear to auscultation, clear to percussion, rales, rhonchi

Eyes

Denies blurred or double vision, vision change, flashing lights, eye discharge, eye pain, irritation, denies corrective lens use.

Gastrointestinal

Denies abdominal pain, nausea, heartburn, blood in stool, and change in bowel habits. Denies diarrhea, constipation, and change in stool.

Ears

Denies hearing change, ear discharge, denies tinnitus and or vertigo.

Genitourinary/Gynecological

Patient denies dysuria, flank/suprapubic pain, urgency, frequency, nocturia, hematuria, polyuria, hesitancy, dribbling, loss of force of stream, passage of stone, edema of face, stress incontinence, hernias, sexually transmitted diseases. Denies vaginal discharge or bleedi

  
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