see attachment
Case Scenario 2
Tables 1
Table 2
Lisa is a 29-year-old female G3P2 at 28 weeks EGA who is coming to the clinic for her routine
checkup. She is Rh negative. Her VS are normal and prenatal routine screenings are WNL. Lisa
GA by weeks Lab Testing and/or
Diagnostic Testing
Medication Expectations
6-10 weeks
10-14 weeks
15-20 weeks
20- 24 weeks
24-28 weeks
28-32 weeks
34 weeks
36 weeks
37 weeks
onwards
Scenario
A normal ongoing pregnancy, the expectation for the
beta HCG level is to _____ (hint: increase by how
much) within 48-72 hours
During a spontaneous abortion (miscarriage), the
expectation for the beta HCG level is to ____ (hint:
decrease by how much) within 48-72 hour
During an ectopic pregnancy, the expectation for the
beta HCG level is to ____ within 48-72 hour
During a molar pregnancy, the expectation for the
beta HCG level is to ____ within 48-72 hour
asks if it is normal to be experiencing frequency and mild burning when she urinates which she says
has increased over the last 2 days. She has been drinking more water recently and thinks that
maybe this is causing the urinary frequency.
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 OB history questions should you ask?
d. What important lab results should you review prior to 28 weeks?
2. Objective:
a. Describe the appropriate physical assessment that needs to be included in this visit.
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 diagnosis?
b. Include any appropriate differential diagnosis
4. Plan:
a. What will you prescribe for this patient? Why? Explain what medications and
treatments you would recommend
HINT: patient should be receiving at least 2 injectable medications at this visit plus oral
medication
b. Explain treatment guidelines and side effects including any possible side effects of
the medication and treatment(s), partner notification, and follow-up plan of care.
c. What patient education is important to include for this patient? What should the
patient expect for the upcoming weeks?
d. Explain complications that can occur if patient does not comply with treatment
regimen.
e. When should the patient return?
Provide evidence from the research 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)
