Comprehensive SOAP note

Post author:top-writer
Post published:April 26, 2020
Post category:Writing Help

P.M. is a 60 yr old Caucasian female presenting for her annual gyn exam. History: Hypertension, Hyperlipidemia, Hysteroscopy w/ Dilation & Curettage, Bladder Prolapse, Post menopausal, Hysterectomy. No concerns today; reports was told to f/u in a year would like a referral for a mammogram screening (concerned that she felt a mass).

Today:
Pelvic Exam
Ultrasound to Breast with Doppler (2×4 mass noted at 3oclock to right breast)
Manual Breast Exam- firm mass palpated and noted to right outer breast
Referral given for a mammogram
Patient to follow up after Mammogram

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