SOAO Note Patient Initials: S.M Pt. Encounter Number: 2 Date: 10/12/2020 Age: 61 Sex: Female Allergies: NKA Advanced Directives: No SUBJECTIVE Chief Complaint: "I have a lump on my right breast." HPI: S.M is a 61-year-old, Hispanic, female who presents to the office alarmed by a painful lump in her right breast that she discovered while showering. S.M reports the pain started 2 days ago while in the shower. The pain is felt when touching the right breast, and it felt on light touch. Current pain level is now 5/10. She does not report any skin changes. Patient denies any history of herbal medicine use and is currently on no medication. Pain gets worse with movement and with lifting weight. Pain is relieved with rest and medication. S.M gets some short relief with pain reliever ibuprofen 200mg that she takes twice a day for the past two days. Past Medical History Medication Intolerances: No known drug intolerance Chronic Illnesses/Major traumas: The patient denies any history of major trauma. Screening Hx/Immunizations Hx: last mammogram, which was normal, was 2 years ago. OBGYN: Menarche at 10; LMP 2 weeks ago; last PAP 2019/Normal; GTPAL: 11001 score; no previous history of STDs. S.M is sexually active, have had 2 sexual partners in the past. S.M used condoms with previous partners. No previous gyn diagnoses or procedures done in the past. Hospitalizations/Surgeries: Hospitalized once for delivery Family History: There is no history of malignancy in first-degree relatives. She has one sister, age 58, who is in good health. Mother died at age 70; father died at age 64, from unknown causes. Social History: S.M is married with one child. No use of alcohol; drinks wine socially; drinks one cup of coffee sometime to start her day at work. Never uses drugs. Review of System Constitutional: No significant gain/loss weight, no chills, no malaise or fatigue; no night sweats, no exercise intolerance. She does not report any skin changes. She has not experienced fever, weight loss, headache, nausea, vomiting, dizziness, or bone pain. Skin: Denies rashes, pigmentation changes, lesions, or hair or nail changes. Eyes: denies vision changes, diplopia, blurred vision, reports wearing eyeglasses. Ears: Denies loss of hearing, ear pain, drainage, sensation of ears feeling full, ringing in the ear, or ear trauma. Nose/Mouth/Throat: Denies sore throat, hoarseness, difficulty swallowing, postnasal drip. No report of mouth or lips sore, bleeding gums, ulcerations or lesions of tongue or mucosa; no dentures or dental appliances, or missing teeth reported. Breast: Refers to right breast pain, or discomfort to right breast. Reports some brownish nipple discharges when squeezing the nipple and denies any breast trauma. Heme/Lymph/Endo: Denies history of anemia, no bruising, no abnormal bleeding, and no swollen glands. Cardiovascular: Denies chest pain, palpitations, orthopnea, edema, claudicati.