Case Scenario 2

Table 1

Table 2

Natalie is a 31-year-old G0 P0 female who complains of intermittent breast pain. She thinks she feels lumps in the outer quadrants of her breasts but is unsure of the location today. She has no family or personal history of cancers, she menstruates regularly, is not pregnant, and uses condoms consistently for BCM and STI protection.

Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.

1.     Subjective:

a.     What other relevant questions should you ask regarding the HPI?

b.     What other medical history questions should you ask?

c.      What other social history questions should you ask?

d.     What other family history questions should you ask?

2.     Objective:

a.     Write a detailed focused physical assessment on this patient. Include the steps in assessment of mastalgia.

b.     Explain what test(s) you will order and perform, and discuss your rationale for ordering and performing each test.

3.     Assessment/ Diagnosis:

a.     What is your presumptive diagnosis? Why?

b.     Any other diagnosis or differential diagnosis you would like to add?

c.      What information is most important in determining whether this is a potentially serious or benign issue?

4.     Plan:

a.     What are your next steps and plan of care for this patient? Explain your rationale

b.     Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s),

c.      What patient education is important to include for this patient? (Consider including pharmacological, supplements, and non pharmacological recommendations and education)

d.     What is the follow-up plan of care?

e.     Explain complications that can occur if patient does not comply with treatment regimen.

Please refer to evidence-based guidelines to support your decision-making.

SOAP NOTE FORMAT

Subjective

CC:

HPI:

Medications:

Allergies:

LMP:

Gyn/OB history:

PMH:

Chronic Illness/ Major trauma:

Family Hx:

Social Hx:

ROS

–  List the body systems and provide answers

–  (Don’t forget to include Gyn ROS)

–  You can include questions here that you’d like to ask the patient

Objective Data

General- provide findings

VS

List body systems- provide findings

–  (Don’t forget Gyn System)

–  (You can include answers here to questions posed in the prompt)

Include POCT (Point of Care testing) not labs that you will send to the laboratoryAssessment/ DiagnosisInclude the ICD10 code

DDX

Plan

Diagnostic tests

Lab Tests

Treatment

Medication

Referrals

Education

Health Maintenance

Follow up

Prompt Questions

(You can include answers here that is asked in the prompt)