Note crustations and deviation of nipple Painless, hard lump in the upper outer quadrant of the left breast with restricted mobility. Social History (SH): Patient is a single female who is currently attending school to obtain her Bachelor’s degree in Business. Frequently, pain occurs or … Pt. 0151 794 8242. clinicalskills@liverpool.ac.uk. 70 Pembroke Place L69 3GF Liverpool United Kingdom. Patient denies any other major family history. Fibroadenomas vary in size, and they can enlarge or shrink on their own.Fibroadenomas are among the most common noncancerous (benign) breast lumps in young wom… Usually painless, it might feel like a marble in your breast, moving easily under your skin when examined. Normal breast examination documentation. Denies discharge, denies dimpling of breast. Says that she began to feel it 3-5 months ago. The SOAPnote Project website is a testing ground for clinical forms, templates, and calculators. Clinical Skills Teaching and Learning Centre. Fibroadenomas (fy-broe-ad-uh-NO-muhz) are solid, noncancerous breast lumps that occur most often in women between the ages of 15 and 35.A fibroadenoma might feel firm, smooth, rubbery or hard and has a well-defined shape. Patient denies any findings of lumps or bumps in her breast exams. Breast Examination documentation examples. Abnormal breast examination documentation. Admits to feeling a small pea sized lump on left breast at 3’oclock point that is painful if touched (“feels like you are pushing in on a bruise”). Breast: pt. Differential diagnosis for breast lump (other than carcinoma): **depends on age, pre- vs post- menopausal 1) Fibrocystic condition: painful, often multiple, usually bilateral masses in the breast.Rapid Fluctuation in the size is common. 10). states that she performs SBE monthly in the shower. Breast exam template. Denies any muscle weakness, symcope, stroke, seizures, paresthesias, involuntary Mother has a history of breast cancer (diagnosed at age 41), for which she underwent a lumpectomy, radiation therapy and is currently taking an aromatase inhibitor. the left breast causing fullness of the areola.

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