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Soap Note # and Diagnosis

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SOAP Note # and Diagnosis

PATIENT INFORMATION

Name: Jane Doe Age: 21 Gender at Birth: Male Gender Identity: Male Source: Patient

SUBJECTIVE DATA

Chief Complaint: “Left breast swelling for 3 months.”

HPI: The patient is a 21-year-old male who presents with swelling in her left breast for approximately 3 months. She denies any associated pain. There is no history of trauma to the area. She reports no recent changes in medication, diet, or lifestyle. She denies any nipple discharge, skin changes, or fever. No prior history of similar issues.

Nutrition History: Patient reports eating a balanced diet and eating on a routine basis. No food intolerances are known; food is stored appropriately and prepared safely in the home. Food availability is not a problem and there have been no recent changes in eating. No history of meal preference or intolerance reported.

ROS:

· Constitutional: No weight loss, fever, or fatigue.

· Eyes: No changes in vision.

· Ears, Nose, Mouth/Throat: No ear pain, no nasal discharge, no sore throat.

· Cardiovascular: No chest pain, palpitations, or shortness of breath.

· Respiratory: No cough, dyspnea, or wheezing.

· Gastrointestinal: No nausea, vomiting, diarrhea, or abdominal pain.

· Genitourinary: No dysuria, frequency, or hematuria.

· Musculoskeletal: No joint pain or muscle weakness.

· Integumentary: Swelling noted in the left breast; no skin rashes or lesions.

· Hematologic/Lymphatic: No easy bruising or bleeding.

· Endocrine: No excessive thirst, no changes in hair or skin.

· Immunologic: No known allergies, no recent infections.

· Neurological: No headaches, dizziness, or numbness.

· Psychiatric: No anxiety, depression, or mood changes.

Allergies (reaction): No known drug allergies. Current Medications: None. Past Medical History: None reported. Immunizations: Up to date. Preventive Care: No recent preventive screenings. Last wellness exam: Over one year ago. Surgical History: None. Family History: No family history of breast cancer. Social History: Non-smoker, occasional alcohol use. Sexual Orientation: Heterosexual. Nutrition History: Balanced diet, no recent changes.

OBJECTIVE DATA

Vital Signs:

· Weight: 145 lbs

· Height: 5’6”

· BMI: 23.4

· BP: 120/80 mmHg

· HR: 72 bpm

· RR: 16 breaths per minute

· Temperature: 98.6°F

· Pain: 0/10

Physical Examination:

· General appearance: Well-appearing, no acute distress.

· Chest: Left breast shows increased tissue compared to the right, no tenderness on palpation, no masses, no skin dimpling, or nipple discharge. Right breast normal.

· Lymphatic: No axillary lymphadenopathy bilaterally.

· Cardiovascular: Regular rate and rhythm, no murmurs.

· Respiratory: Clear to auscultation bilaterally, no wheezing or crackles.

· Abdomen: Soft, non-tender, no masses.

Neurologic Examination:

· Mental Status: Alert and oriented to person, place, time, and event.

· Cranial Nerves: Cranial nerves II-XII intact.

· Motor Strength: 5/5 bilaterally in upper and lower extremities.

· Reflexes: 2+ throughout.

· Sensory Function: No sensory deficits noted.

· Balance and Gait: Normal gait and balance.

· Coordination: Coordination intact.

ASSESSMENT

Main Diagnosis: Gynecomastia (ICD-10 N62):

Gynecomastia is a benign enlargement of male breast tissue, usually due to a hormonal imbalance with high levels of circulating estrogen, very low free testosterone, and an altered ratio of estrogen to androgen (Vandeven & Pensler, 2020). Though this can manifest in females as well, through rare occasions where elevated estrogen levels occurred, most of the time, this problem is concomitant in male cases. In this patient, hormonal influence may be suggested since the swelling of the breast is unilateral, painless, and without masses. Possible causes of gynecomastia can be isolated to puberty, medication, or underlying endocrine disorder (Vandeven & Pensler, 2020). Although the condition is not malignant, there must be further investigation in ruling out underlying conditions like hormonal abnormalities, liver disease, or testis abnormalities. Confirmation of the diagnosis requires diagnostic studies, including hormonal panels and imaging.

Differential Diagnosis:

1. Fibroadenoma (ICD-10 D24.0)

Fibroadenomas are benign tumors of the breast and usually present in young women. Usually, it presents as a firm, painless, mobile lump in the breast. While they more often present in both breasts, sometimes they can present unilaterally, as in the case of this patient (Ajmal & Fossen, 2022). They are caused by an overgrowth of glandular and connective breast tissue. While these usually do not cause any significant discomfort, they may grow or change in size due to fluctuations in hormonal stimuli, such as, for example, during pregnancy or menstruation. Ultrasound is indicative in distinguishing a fibroadenoma from other lesions of the breast, while biopsy can be important to confirm the diagnosis if atypical features are present.

2. Carcinoma of breast- (ICD-10 -C50.919):

While less likely in the present case without a palpable mass, pain, or changes to the overlying skin, one should still consider breast carcinoma, especially in women with an asymmetry of the breast. Nipple discharge or skin dimpling is denied by the patient, but early breast cancer can sometimes presenting little or no alarm (Wu et al., 2022). Risk factors include a family history, hormonal therapies, and age. Diagnostic evaluation can usually only be made using mammograms or an ultrasound with the possibility of having a biopsy to the side of malignancy; it should be excluded, although it is rare in such young patients, to be able to have timely intervention if ever needed.

3. Hormonal Imbalance (ICD-10 E29.1)

Those hormonal imbalances, including disorders of the levels of estrogen and progesterone, can be responsible for breast swelling, tenderness, and tissue changes. In these patients, increased levels of oestrogens or low levels of progesterones and testosterone both may result in the development of more breast tissue at one side (Satpathi et al., 2023). Some possible causes of hormonal disturbances include polycystic ovarian syndrome, pituitary adenoma, or thyroid derangement. A basic diagnosis of the underlying cause is helpful, and a blood test for the measurement of hormones including FSH, LH, and prolactin together with thyroid function tests is necessary for this. Treatment would include the use of hormones or medication that could bring the hormone concentrations to normal distributions, or treatment of the etiological cause where hormonal imbalance is established.

Summary of the Case and Diagnosis

The 21-year-old male reports unilateral, painless breast enlargement consistent with gynecomastia per ICD-10 N62. Based on patient history and clinical presentation, gynecomastia in this patient can most likely be attributed to a hormonal imbalance. Differential diagnoses include fibroadenoma ICD-10 D24.0, carcinoma of the breast ICD-10 C50.919, and hormonal imbalance ICD-10 E29.1. These diagnoses need further diagnostic workup, including radiology and blood work, to confirm the primary diagnosis and rule out other causes.

PLAN

https://doi.org/10.1007/s44178-022-00007-8

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