SOAP NOTE- PAGET DISEASE OF THE NIPPLE

Paget Disease of the Nipple-SOAP Note

Instructions

This is a soap note to be done on a female patient with a primary diagnosis of Paget Disease of the Nipple

Differential diagnosis: Eczema, and psoriasis.

INCLUDE ICD 10 CODE WITH DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
Use both the templates attached.

NRNP 6552 Focused SOAP Note Template WK4

GYNHistory and Physical Template: cervices
Make sure to complete all sections and include Pelvic Exam information and full Neurology assessment as indicated in the outline.

References no later than 2019.

Solution

Paget Disease of the Nipple-SOAP Note

SOAP Note

Patient’s Details

Initials: D.P.             Age:  38 years                       Race: White                      Gender: Female

SUBJECTIVE:

Chief Complaint (CC): “The nipple of my right breast is painful, itchy, scaly, and red. I also feel a burning sensation in the nipple area.”

History of Present Illness (HPI): D.P., a 38-year-old white woman with two children with last menstrual period occurring two weeks ago has reported to the clinic complaining of pain, itchiness, redness, and a burning sensation in the right nipple. These symptoms started a week ago. D.P. also reports that the skin covering the nipple is scaly and is ulcerated.

The nipple bleeds quite often due to constant scratching. The itchiness and pain are persistent and they occur almost all the time. Further reports indicate that the pain and itchiness are so severe that they affect the patient’s ability to concentrate in other activities. D.P. denies nausea, fatigue, and vaginal bleeding.

Medications: Does not use any medications at the moment.

Allergies: Denied both drug-related and food-related allergies.

Menstrual history: Menarche was at 13 years. Menstrual cycle is 28 days and menses last for 4 days with minimal cramping. Her last menstrual period was two weeks ago on 7^th October, 2021.

Gynecologic history: Denies a history of breast disease. D.P. has never obtained a breast exam before.

Contraceptive/sexual history: Denies use of hormonal contraceptives. She is sexually active and reports the use of condom with partner as means of contraception.

PMH: Childhood diseases as per available medical records were measles, chicken pox, and pneumonia. D.P. denies being diagnosed with any serious medical condition during adulthood.

Social History: The patient is currently married with two children; a girl and a boy aged 18 and 15 years respectively. Her husband is 44 years old. D.P. is currently employed as a secretary in a nearby coffee factory. She denies consuming alcohol or cigarettes.

Family History: Father is 67 years old and does not have any underlying medical conditions. Mother is 60 years and was diagnosed with breast cancer 2 years ago. Her husband and their two children are healthy.

Review of Systems (ROS)

General: Denies abnormal weight gain or weight loss, denies body weakness, fatigue, or fever. Denies nausea and vomiting.

Skin: Denies skin rashes, skin erythema, or abnormal changes in skin color. No changes in nail structure and appearance reported.

HEENT:

Head: Denies headache or head trauma/injury.

Eyes: Does not report issues with vision, pain in the eyes, or excessive tearing. Does not use glasses/contact lens.

Ears: Denies hearing loss. Does not report changes in hearing or ringing in ears. Denies a history of ear infections.

Nose and Sinuses: No frequent colds reported. Denies nasal stuffiness or nosebleeds. No obstruction, pain, or discharge reported. The patient denies sneezing or any challenges while breathing through the nose.

Mouth and throat: Denies mouth ulcers or soreness in the tongue. Does not report hoarseness or soreness in the throat. No issues with teeth or gums reported.

Neck: Denies lumps or swollen lymph nodes in the neck region. The patient further denies goiter or pain on the neck.

Lymphatics: Denies swollen lymph nodes in neck area

Breasts: Does not report lumps in the breasts. Reports pain, bleeding, itchiness, redness, and a burning sensation in the right nipples. The patient further reports that the right nipple is ulcerated and scaly.

Pulmonary: Denies a cough, wheezing, or difficulty breathing. Does not report pain in the chest during inhalation and exhalation.

Cardiovascular: D.P. denies chest pain or dyspnea. Denies shortness of breath, tightness of the chest, or orthopnea. Does not report edema, hypertension, a history of a murmur, or known heart disease. Denies pain in posterior calves with walking or a history of an abnormal electrocardiogram.

Gastrointestinal: Denies dysphagia or trouble swallowing food. Does not report pain with swallowing and denies nausea or vomiting. The patient also denies changes in appetite, food intolerance, heartburn, diarrhea, constipation, or indigestion. She does not report changes in bowel pattern, abdominal pain, rectal bleeding, or a history of hepatitis

Urinary: Denies hematuria of the presence of blood in urine. Also denies pain on urination (dysuria), changes in urination frequency, especially at night. Denies pain during urination or polyuria. Does not report a history of urinary tract infections.

Genital tract: Age of menarche was 13 years, last menstrual period was two weeks ago on 7^th November 2021, her menstrual cycle is 28 days, menses last for 4 days. Denies postcoital bleeding or pain with intercourse. Does not report vaginal discharge or pruritus. Denies hormonal contraceptive use but reports condom use. Denies a history of sexually transmitted diseases (STDs). She has never had a pap smear before. D.P. has never had a still birth or abortion. She also denies complications with pregnancy.

Musculoskeletal: Denies joint pains or muscle stiffness. Denies a history of arthritis, joint swelling, or gout. Denies backache, a history of fractures, or limitation of motion.

Neurologic: Denies overall body weakness. Denies fainting, dizziness, or headache. Does not report tingling, numbness, or tremors in the extremities.

Psychiatric: Denies depression, anxiety, insomnia, nightmares, or irritability. Does not report phobias or any suicidal thoughts.

Endocrine: Denies excessive sweating. Does not report thyroid issues and denies heat or cold intolerance. Denies excessive urination, thirst, or hunger.

Hematologic: Doe not report past transfusions. Denies blood-related diseases such as anemia and disorders like hemophilia and sickle cell disease.

OBJECTIVE:

Physical Exam:

VS: Temperature: 36.7 degrees Celsius; Height=44 inches; heart rate=92, respiratory rate=20, weight=69.5 lb, BMI: 20.1, BP:110/70, Sp02: 98% on room air.
General: Alert, awake, and oriented. Well-groomed and neat, no evidence of acute distress. Appears strong attentive.
Skin: Skin is intact without rashes or lesions. It is warm and dry. No evidence of abnormal skin color based on ethnicity. No clubbing or cyanosis on nail beds. Nail beds are pink.

HEENT:

Head: The head is atraumatic, normocephalic, and without tenderness. No visible scarring or palpable masses. Hair is evenly distributed on the scalp and it is of normal texture.

Eyes: Conjunctivae are without exudates and are clear. No evidence of hemorrhage. Non-icteric sclera observed. Eyelids have no lesions or swelling and have normal appearance.

Ears: Pinna are visible symmetrically positioned on both sides of the head. The ear canal is clear, non-tender, and without edema. No evidence of ear discharge. Normal tympanic membrane is observed in both ears.

Nose: Moisture and pink color observed in the nasal mucosa. The nasal septum is located midline.

Throat: Mucosa in non-ulcerated. Tongue is in good movement and it is pink in color. The throat is non-erythematous. No lesions, exudates, or edema are observed in the throat and the pharynx.

Neck: Trachea is midline. The neck is without adenopathy and it is supple. Thyroid gland is not swollen. Carotid pulse is without bruit and it is 2 + bilaterally.

Cardiac: The chest is without heaves, thrills, or lifts. Point of Maximal Impulse (PMI) is not visible on palpation in the midclavicular line at the 5th intercostal space. No evidence of abnormal heart rate and heart rhythm. No gallops, no murmurs, no rubs. S1 and S2 are heard and are of normal intensity.

Respiratory: The chest wall is without deformity and appears symmetric. No evidence of trauma observed. The chest wall is non-tender. No evidence of respiratory distress. Clear lung sounds in all lobes. No wheezes, rales, or ronchi. Percussion of all lung fields has revealed signs of resonance.

Abdominal: Abdomen is non-tender, soft, and symmetric. It is without distention. No visible scars or lesions. Umbilicus is without herniation and it is positioned midline. No bowel sounds in all four quadrants. No evidence of splenomegaly or hepatomegaly.

Breasts: The right nipple is red, scaly, and ulcerated. It is also flattened. The breast is non-tender and without lumps. No evidence of discharge but there is evidence of bleeding.

Pelvic Exams/Genitals: Vagina is pink and moist without lesions or discharge. External genitalia is normal in appearance without lesions, edema, masses or tenderness. Vaginal walls are well rugated. No evidence of vaginal discharge. Cervix is non-tender without lesions or erosion. Uterus is non-tender with no evidence of gestation. No palpable masses or enlargement in the ovaries. The ovaries are non-tender.

Musculoskeletal:

Spine: No deformity on the neck and back. No evidence of trauma. Her posture is upright with no abnormal gait. The spinous processes are non-tender and are positioned midline. No spasm on the lumbar paraspinal muscles. No evidence of discomfort is observed with flexion, extension, and side-to-side rotation of the cervical spine. Evidence of full range of motion is observed. The thoracic and lumbar spine show evidence of full range of motion on extension, flexion, and side-to-side rotation.

Extremities: Lower and upper extremities are without trauma in appearance. No evidence of tenderness or deformity observed. Lower and upper limbs have no edema or erythema. There is full range of motion on all joints. The Muscle strength is 5/5 bilaterally. Normal tendon function observed. All extremities have capillary refill of less than 3 seconds.

Neurological Assessment: D.P. is alert and oriented to person, place, and time. She has normal speech. No evidence of pain in the nerves. Both upper and lower limbs are sensitive to changes in pain.

Psychiatric: No evidence of psychological disturbance. No auditory or visual hallucinations. No suicidal or homicidal ideation detected. The patient has appropriate mood and affect.

Diagnostic tests:

• Breast exam: To check of lumps, deformities, or swollen lymph nodes (MFMER, 2021; Bickley et al., 2020).
• Mammogram: To find out whether there are abnormal growth or cancerous cells in the both breasts (MFMER, 2021).
• Breast ultrasound: Detects lumps or fluid-filled cysts (MFMER, 2021).
• Magnetic resonance imaging of both breasts: To assess abnormalities in breast structures and tissues (MFMER, 2021).
• Laboratory test: Obtain biopsy of breast tissues and analyze to determine whether they contain cancer cells (MFMER, 2021; Dains et al., 2019).

ASSESSMENT:

Differential Diagnoses

• Paget’s disease of the nipple (primary diagnosis)
• Eczema
• Psoriasis

ICD 10 CODES

Paget’s disease of the nipple (Primary diagnosis)

• C50.019: Malignant neoplasm of nipple and areola, unspecified female breast (ICD10data.com, 2021a).

Differentia diagnoses

Eczema

• L20.9: Atopic dermatitis unspecified (ICD10data.com, 2021b).

Psoriasis

• L40.9: Psoriasis, unspecified (ICD10data.com, 2021c).

References

Bickley, L., Szilagyi, P., Hoffman, R., & Soriano, R. (2020). Bate’s guide to physical examination and history taking (Lippincott Connect). 13^th ed. Philadelphia: Wolters Kluwers.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

ICD10data.com. (2021a). 2022 ICD-10-CM Diagnosis Code C50.019: Malignant neoplasm of nipple and areola, unspecified female breast. https://www.icd10data.com/ICD10CM/Codes/C00-D49/C50-C50/C50-/C50.019#:~:text=Billable%2FSpecific%20Code-,C50.,a%20diagnosis%20for%20reimbursement%20purposes.

ICD10data.com. (2021b). 2022 ICD-10-CM Diagnosis Code L20.9: Atopic dermatitis unspecified. https://www.icd10data.com/ICD10CM/Codes/L00-L99/L20-L30/L20-/L20.9.

ICD10data.com. (2021c). 2022 ICD-10-CM Diagnosis Code L40.9: Psoriasis unspecified. https://www.icd10data.com/ICD10CM/Codes/L00-L99/L40-L45/L40-/L40.9.

Mayo Foundation for Medical Education and Research (MFMER). (2021). Paget’s disease of the breast: Diagnosis. https://www.mayoclinic.org/diseases-conditions/pagets-disease-of-the-breast/diagnosis-treatment/drc-20351084