## SOAP Note for Mastitis without Abscess
**Patient Information:**
– **Name:** [Patient’s Name]
– **Date:** [Date]
– **Age:** [Patient’s Age]
– **Gender:** Female
—
**S: Subjective**
– **Chief Complaint:** “I have pain and swelling in my breast.”
– **History of Present Illness:** The patient is a [age] female who presents with a 3-day history of breast pain, localized swelling, and redness in the left breast. She reports fever and chills. The pain is described as throbbing, rated 7/10 in intensity. The patient is currently breastfeeding and notes that the affected breast has been difficult to empty.
– **Past Medical History:** No significant history of breast issues. No previous surgeries.
– **Medications:** [List any medications]
– **Allergies:** No known drug allergies.
—
**O: Objective**
– **Vital Signs:**
– Temperature: [e.g., 101°F]
– Heart Rate: [e.g., 80 bpm]
– Blood Pressure: [e.g., 120/80 mmHg]
– **Physical Examination:**
– **Breast Examination:**
– Left breast: Warmth, redness, and tenderness noted. Swelling present but no fluctuation or central mass detected.
– No palpable lymphadenopathy in the axillary region.
– **General Appearance:** Patient appears fatigued but is in no acute distress.
—
**A: Assessment**
– **Diagnosis:** Mastitis without abscess. Likely caused by blocked milk ducts or bacterial infection, exacerbated by breastfeeding difficulties.
– **Differential Diagnoses:**
– Breast abscess (ruled out due to absence of fluctuating mass)
– Non-infectious mastitis
– Paget’s disease of the nipple (less likely due to lack of skin changes)
—
**P: Plan**
1. **Medications:**
– Prescribe antibiotics (e.g., Dicloxacillin or Cephalexin) for suspected bacterial infection.
– Recommend analgesics (e.g., Ibuprofen) for pain and inflammation.
2. **Breast Care:**
– Advise frequent breastfeeding or pumping to empty the breast and relieve pressure.
– Instruct on warm compresses to soothe pain and promote drainage.
3. **Follow-up:**
– Schedule a follow-up appointment in 48-72 hours to assess improvement.
– Educate the patient to return if symptoms worsen or if a lump develops.
4. **Patient Education:**
– Discuss signs of complications, including fever escalation and the development of a breast abscess.
– Provide guidance on proper breastfeeding techniques and positions to avoid engorgement.
—
**Signature:**
– **Provider Name:** [Your Name]
– **Title:** [Your Title]
– **Date:** [Date]
—
Please replace placeholders with actual patient information and adjust clinical details as needed for accuracy.
– 1 soap note about MASTITIS WITHOUT ABSCESS
– Please use template form attached.
– 0 plagiarism
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