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Case Study SOAP NOTE: MACROPROLACTINOMA
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Case Study SOAP NOTE: MACROPROLACTINOMA
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Running Note: SOAP NOTE: MACROPROLACTINOMA 1SOAP Note: Macroprolactinoma
Identifying Data and Chief Complain
A 43yearold female, Puertorican, and divorced, comes to the clinic for an initial visit
complaining of oligomenorrhea and galactorrhea. She refers that “I’m having irregular
menstrual periods, sometimes twice in a month and others, every two or three months. At this
moment, I do not have menstruation for the last two months. I am having milky discharges in
both breast nipples for approximately two months”. She also refers that “I am suffering from
headaches that are increasing in frequency and intensity. I am having blurred vision and hair
growth in my face, too.” Patient explains that is using Fioricet for pain when headache is
intense, because acetaminophen is not effective controlling it. The patient refers that these
problems started five months when she was living in New York City. She visit there her primary
care physician (PCP), who ordered laboratories and a MRI. She lost laboratories results but has
the MRI with her. She did not go back to the PCP with the results, because her mother is sick
and she moved to Puerto Rico last February to take care of her. Patient has the state health
insurance, Mi Salud and she is the primary cardholder.
Subjective Symptoms
1. “irregular menstrual periods”
2. “milky discharges in both breast nipples”
3. “headaches that are increasing in frequency and intensity”
4. “blurred vision”
5. “hair growth in face”
,SOAP NOTE: MACROPROLACTINOMA 2
Subjective Data
Past medical history (PMH): Patient informs that she had a healthy childhood. Menarche was
at 11 years old. LMP: January 30, 2016. G:2 P:2 A:0. She has a 15-year-old daughter and a 13-
year-old son and do not have complications during pregnancy. Patient refers oligomenorrhea,
galactorrhea and headaches. She denies chronic diseases. Last Pap Test was in November 2015-
negative. Immunizations are up to date, including influenza (March 21, 2016).
Family history: Patient has a healthy 15-year-old daughter and a healthy 13-old-old son. Her
mother is a 64-year-old woman with hypertension and a recent CVA. Her father had 63-year-old
when died from colon cancer. She has a 40-year-old healthy brother. Her grandfather from the
father’s side had 83-year-old when died from ESRD. Her grandmother from the father’s side is
86-year-old woman with RA and osteoporosis. Her grandfather from the mother’s side had 71-
year-old when died from MI. Her grandmother from the mother’s side is a 75-year-old woman
with hypothyroidism and obesity.
Past social history (PSH): Patient refers no toxic habits in the past and present time. She is
divorced for 10 years. She is Christian. She is not sexually active. Patient lives in her mother’s
house with her daughter and her mother. She was working in a factory, but is currently
unemployed. Patient denies exercise.
Immunization: All vaccines are up to date, including influenza (March 21, 2016).
Allergies: No known allergies (NKA).
Surgical history: Sterilization by laparoscopy.
Medication history: She is using Fioricet for intense headache. No other medication history.
, SOAP NOTE: MACROPROLACTINOMA 3
Subjective Symptoms and Review of Systems (ROS)
Constitutional: Patient denies weight changes during the last year.
Skin: Patient refers hair growth in face. She denies lesions, acne, dry skin, pruritus, nodules,
new moles, dry hair or eczema.
HEENT: Patient refers blurred vision. She reports contact lenses (myopia) and eyeglasses for
reading. She indicates no hear difficulty or tinnitus, no congestion, no dental or swallowing
problems.
Respiratory: Patient denies rhinitis, dyspnea, hemoptysis, cough or secretions.
Cardiovascular: Patient denies tachycardia, bradycardia, palpitations, orthopnea or chest pain.
Gastrointestinal: Patient denies diet changes. She reports a healthy diet with fruits, vegetables
and low in sodium and carbohydrates. She denies abdominal pain, has normal bowel movements
and no changes in elimination frequency or consistency, no indigestion or heartburn.
Genitourinary: Patient complains of oligomenorrhea and milky discharges from both breast
nipples. She denies abdominal and/or pelvic pain during menstruations. She denies pain or
burning during urination, no genital lesions, and hematuria. Patient denies STDs. She is not
sexually active.
Musculoskeletal: Patient denies myalgia, weakness, difficult to walk, fractures or cramps. No
pain or fluid retention in hands, legs or feet.
Neurologic: Patient denies dizziness, migraines, disorientation, involuntary movements,
numbness, tingling, anxiety or depression. Patient reports intense headaches.
Hematologic: Patient denies easy bruising, nose or gums bleeding, rectal or urethral bleeding.
Endocrine: Patient does not have hirsutism, cold intolerance or mood changes.
Allergic: Patient denies allergies to food and/or medications.
Objective Data (Physical Examination)
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