41 years

5′ 3″
155 pounds

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.

• 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.
• Include three differential diagnoses and support your diagnoses with supporting literature.

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. 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. 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 Paper

 

MORE INFO 

SOAP Note and Differential Diagnoses for iHuman Case.

Introduction

Hello,

I am Dr. John, and I’ve been asked to write a brief summary of the case study you submitted for my PhD program at the University of Minnesota. Your research question was “How does a team of clinicians working with iHuman interact with it?” You will be graded on the quality of your writing as well as the quality of your analysis and interpretation, so please read this carefully before submitting any further work:

Subjective data:

• Name of patient: This is the first thing you should look at when evaluating a case. You need to know who your patient is, what they look like and where they live. Knowing these things will help you understand their illness better, which in turn helps with diagnosis of course.

• Age/Gender: In general, most people have an idea of how old they are based on their appearance but sometimes this can be misleading or even incorrect depending on where they live or what time period in history we’re talking about here (iHumans tend to grow more slowly than humans). If there’s any doubt whatsoever about someone’s age then ask them! It might be helpful if everyone who comes through our doors does so with confidence that no one else has ever asked us before.”

Goal and objective data:

Goal and objective data

• Goals: The patient’s goals are to improve his health and quality of life, as well as to increase his sense of self-efficacy.

• Objectives: These are the patient’s specific objectives for treatment that have been agreed upon by both parties (iHuman and physician). They must be specific enough to allow for clear communication between you, the physician, and your iHuman.

Major assessment findings include the following:

The major assessment findings include the following:

• Subjective data – The patient has subjective complaints of pain and fatigue, but denies any other symptoms.

• Goal and objective data – There are no gross or microscopic findings on either physical examination or laboratory testing that would suggest a systemic disease process causing these symptoms. In addition, there is no evidence of altered mental status (e.g., confusion, disorientation) or autonomic dysfunction (e.g., tachycardia).

Differential diagnoses (DDx):

In this section, we will discuss the possible causes of your patient’s symptoms. These can include both physical and mental/emotional causes. The list is long, so it’s important that you consider all factors when making a differential diagnosis.

Some examples:

• The patient has developed an infection in their lower back that was not mentioned in the initial visit because they were not concerned about it at that time (this would be considered an organic cause).

• The patient had been injured in an accident during which their brain was damaged (this would be considered a psychosocial cause).

• They were taking medications for depression or anxiety that may have caused some of their symptoms (this would be considered a medical cause).

Plan of care (POC) & Diagnostic Testing:

The plan of care is an important part of the SOAP note. It is a summary of your doctor’s plan for you, which includes specific goals and objectives. The plan also includes any diagnostic testing that has been performed on you.

The POC should be written as follows:

• Patient name (print)

• Date signed by patient (print)

• Physician’s name(print)

• Signature(print)

Takeaway:

The takeaway is that you should be aware of the different types of iHuman cases and how they can affect your patients. This will help you determine which medications to use in the case of an iHuman attack and also how best to treat their symptoms.

Conclusion

The differential diagnosis for iHuman case is very broad in nature. We have discussed all the possible etiologies of this condition and you can use them as a reference while you are working on your case. You can also consult with other experts if they have made any progress in their research or studies