Week 6 DB

Case Scenario 1- Complete the chart and answer the case scenario

Kelly is a 19-year-old female who comes to your clinic complaining of severe menstrual pain that is usually worse just prior to and during the first two days of her menses. The pain is sometimes so severe that she has fainted. She states that defecation can cause severe pain and she therefore frequently becomes constipated. She often must miss work when experiencing the severe pain. Her periods are heavy and last seven days with a tapering of the bleeding from days 3 to 7. Her BMI is 23.9 and her VS are all WNL. She is G0 P0.

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?

Diagnosis Definition Presentation/

Sign and Symptom

Management

Bartholin Cyst

Squamous Carcinoma of the Vagina

Adenocarcinoma of the Vagina

Lichen Sclerosus

Lichen Planus

Lichen Simplex Chronicus

Vulvodynia

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. 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?

4. Plan: a. How will you manage this patient? What treatment or medication would you prescribe

and why? 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)