see attachment
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?
Definition Presentation/
Sign and
Symptoms
Management
Mastalgia
Mastitis
Nipple Discharge
Breast Mass
Nipple Changes
Diagnostic test How is this test helpful in breast conditions
Screening
Mammogram
Diagnostic
Mammogram
Breast
Ultrasound
MRI of the Breast
Biopsy (FNA and
CNB)
Surgical Biopsy
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)
