Come up with a chart note for

Come up with a chart note for the patient based on these following information. Your chart note must include a patient history including her chief complaint, history of present illness, past medical/surgical, family, and social histories, medications, and allergies. You will also develop a patient care plan stating the active diagnosis and next steps for treatment and follow up. Consider any consults that would be necessary to augment a successful outcome for the patient. The patient history and care plan are the most important. ———– Janet Laws-Patient Information ChartSources of Patient Information: Patient: Janet Laws Date of Visit: April 18, 2022 Date of birth: July 4, 1961 Patient reports: I am healthy and have no health concerns except for cancer in my left breast I found a lump in my breast and my doctor sent me an order for a mammogram I have mild arthritis in hands and knees for the past few years and my blood pressure is sometimes high and I am allergic to penicillin I have occasional constipation but no nausea or vomiting I do not smoke, drink alcohol, or use drugs. I do have an occasional glass of wine I had my appendix out as a child and fear surgery and needles My dad died in combat in the military and my mom died in a car accident. I am an only child I am married with two grown children and three grandchildren My health care is provided by my family practice doctor, I have not seen a cancer specialist My husband and I have plans to travel when he retires shortly so I will not have time for long term cancer treatment, plus I have heard that chemo and radiation have a lot of side effects especially making it hard to eat. Spouse reports: He confirms their travel plans in a RV when he retires in 6 months He does not believe his wife will agree to change their plans by being tied down to cancer treatment after surgery and agrees with his wife that the surgery to remove the lump should be adequate. He doesn’t want her to have a long recovery period. He worries this would be very stressful for both of them. Radiology Associates report: April 11, 2022 diagnostic mammogram per LMD order Biopsy and work up at Orlando Cancer Center Report- scans and biopsy found a 6 cm mass in the axillary region of the left breast with questionable involvement of the left axillary lymph nodes. Possible stage IIIA breast cancer to be confirmed by pathology reports following surgery. Nurse report: Recent unintentional 10-pound weight loss, often feels tired Ht: 5’6″ Wt: 110 pounds Seems quiet, but willing to answer questions with short answers, no obvious hearing or speech concerns Speaks English and agrees to verbal or written information, wears reading glasses No fever, no flu like symptoms, has received both vaccines for COVID No breathing, heart problems, or other health problems per patient other than occational high blood pressure No change in bowel or bladder patterns other than occasional constipation Vitals- Temperature: 98.7 F; heart rate 75 bpm; Respiration 18 bpm; BP 149/88; Pain 4 in knees and hands, and left breast with palpation during exam Lab reports: Complete Blood Count and Comprehensive Metabolic Panel all within normal limits Provider report: by Mary Smith, M.D Vitals per nurse report Medications: low dose aspirin 1/d, multivitamin for women 1/d, lisinopril 5MG/d Physical exam normal except as noted by other reports. Breast exam abnormal mass can be felt in left breast near the axilla. Review of Systems: Constitutional: Alert and oriented, no acute distress, recent unintentional 10-pound weight loss, fatigue, no signs of illness HEENT: wears reading glasses, no discharge or sore throat Cardiovascular: high blood pressure Respiratory: no cough, no flu-like symptoms Gastrointestinal: no nausea, emesis, diarrhea, occasional constipation Genitourinary: no changes or issues Musculoskeletal: ongoing pain and stiffness in bilateral knees and hands Integumentary: no rash, lump in left breast is palpable Neurologic: no speech difficulty, no change in vision Endocrine: no changes or issues Hematologic/Lymphatic: questionable involvement of left axillary lymph nodes Physical Examination: Vital signs: Vitals- Temperature: 98.7 F; heart rate 75 bpm; Respiration 18 bpm; BP 149/88; Pain 4 in knees and hands and left breast with palpation during exam. Ht: 5’6″ Wt: 110 pounds Constitutional: Anxious 60-year-old female appears thin, but in general good health; awake and alert; oriented to time, person, and place, in no acute distress HEENT: head normal in appearance, wears glasses for reading, no discharge or sore throat Cardiovascular: High blood pressure, heart rate within normal limits, regular rhythm, no murmur is present, no gallop is present Respiratory: rate within normal limits; breath sounds are normal Integumentary: no rash/lesions or cyanosis; palpable mass on the left lateral edge of the left breast, near axilla. Non mobile, edges not defined. No puckering or dimpling of skin. Area is tender to deep palpation Hematologic/Lymphatic: lymph nodes of the left axilla are enlarged. Digestive: abdomen soft, distended, non-tender, bowel sounds normal Genitourinary: female pelvic exam not done. Neurological: gait normal, cranial nerves intact, strength normal, sensation exam normal, reflexes normal, cerebral function normal Musculoskeletal: synovial joints of the phalanges allow full ROM with mild discomfort; tenderness in knees but no edema. Medications: Low dose aspirin 1/d, multivitamin for women 1/d, lisinopril 5MG/d Recent Labs/Radiology/Procedures: Lab results: within normal Fine needle aspiration results: indicate neoplasm of the left breast with possible axillary lymph node metastasis SCIENCE HEALTH SCIENCE NURSING NUR 1401C

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