Problem: In SOAP format , Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals and other team members needed to complete patient care.
Julia is a 37-year-old woman G2P2 who presents with a lump in her left breast. Her husband noticed it recently and she is concerned, because her aunt had breast cancer and she thinks that a great-grandmother or some other ancestor may have died of breast cancer as well. Both of her children, who are ages 9 and 7, were delivered without complications and she breastfed "for well over a year" with each. She has no other significant PMH or allergies. She is 5' 6" tall, weighs 144 pounds, and has a BMI of 22. Julia works as an office manager. She is a non-smoker, considers herself to be a "meat lover," and drinks 2 to 3 glasses of wine most evenings with dinner. Her last physical exam was over 10 years ago. Upon examination, a lump is discovered. It is firm and near the surface and no other masses are discovered. The lump is aspirated and an opaque liquid is removed. Following this procedure, the lump vanishes.