See attachment
Case Scenario 2:
Complete the charts and answer the case scenario.
2018 USPSTF Guidelines 2021 ACS Guidelines
Age 21-24
Age 25-29
Age 30-65
Age 65 and older
American Cancer Society Recommenda1ons for the Early Detec1on of Cancer in Average-Risk, Asymptoma1c Adults
CANCER
SITE
POPULATION TEST OR
PROCEDURE
RECOMMENDATION
SUMMARY
Breast
Cervix
Colorectal
Endometrial
Ellen is a 35-year-old female whose latest Pap smear result reports HSIL with positive HPV.
Ellen reports no h/o of STIs or previous abnormal Pap smear results. She had only two previous
Pap tests 7 and 14 years ago. Ellen is G1P0 with a TAB at age 25. She and her partner are
undecided whether they want to have children. She has been monogamously married to a female
partner for the last 5 years, but she considers herself bisexual and has previously engaged in
sexual activities with males and females. Ellen denies any significant medical history or current
health problems. Her LMP was 5 days ago and her VS are WNL. Her BMI is 24.7. Her
pregnancy test is negative.
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?
2. Objective:
a. What other point of care testing (POCT) would you perform or order for this
patient? Why?
3. Assessment/ Diagnosis:
a. What would be an appropriate diagnosis for her? Explain Ellen’s Pap smear
results (pathophysiology) and the action(s) that will be taken next to follow up
this abnormality, including patient education (explain the procedure to the
patient).
4. Plan:
a. What will you prescribe for this patient? Why?
b. What patient education is important to include for this patient?
c. Is there any education or advice you would give to Ellen regarding her current
female partner?
d. What pharmacological and non pharmacological education and advice can you
give Ellen to help with her HSIL condition?
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 laboratory
Assessment/ Diagnosis
Include 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)
