soap notes ch14

Sophia Rios, a 33-year-old nurse, visited Kaiser Permanente Walnut Creek Medical Center on May 6, 2024. She complained of tenderness, sharp pain, and heat around her breast. Dr. Gonzales conducted an examination and found hardness in the breast area, indicating a possible breast disease. The assessment suggested it could be mastaliga, mastitis, or fibrodynamia. Treatment options include vitamin E or evening promise oil for mastaliga, antibiotics for mastitis, and surgery to remove the tumor for fibrodynamia. Kaiser Permanente Walnut Creek Medical Center, Dr. Gonzales, May 6, 2024. Patient name, Sophia Rios, age 33, occupation nurse. Subjective, feeling tenderness around her breast, having sharp pain towards her chest, feeling heat around her breast. Objective, showing normal signs, palpation shows hardness around the breast area, may be showing some sort of breast disease. Assessment, may be mastaliga, mastitis, or fibrodynamia. Treatment plan for these are for mastaliga, you can use vitamin E or evening promise oil. For mastitis, there's antibiotics to treat the infection. For fibrodynamia, there's surgery to remove the tumor.