Chapter 8: The Male and Female Reproductive Systems | Nancy Hopps's Chart Note

CHART NOTE

Patient Name: Hopps, Nancy
ID Number: HN 25780
Examination Date: January 12, 20xx

SUBJECTIVE
Mrs. Nancy Hopps is an 82-year-old female who is new to this practice. She was referred by her primary care physician after physical examination confirmed a lump in her right breast.

OBJECTIVE
Vital signs within normal limits, although BP is slightly elevated. Physical exam reveals a significant, easily palpated (lightly pressed with the palms and fingers) lump of the right breast that is somewhat hard with irregular borders.

ASSESSMENT
Possible breast carcinoma.

PLAN
Mammogram and a breast ultrasound will be performed in our office and sent to our radiology group for analysis.