Case Scenario 1
Table 1
|
Define: |
|
|
Perimenopause |
|
|
Menopause |
|
|
Postmenopause |
|
|
S/S |
Cause -How |
Recommendations |
|
Example: |
Lower |
Having a |
|
Hot
|
|
|
|
Night |
|
|
|
Irregular |
|
|
|
Mood |
|
|
|
Vaginal |
|
|
Barbara is 48-year-old female who complains her menstrual cycle has recently become irregular, and she is experiencing hot flashes and vaginal dryness. She has also noticed a decrease in her desire for sex lately. She has been married to a man for 20 years, is in a stable relationship, and has two daughters ages 16 and 18. She is otherwise healthy with an unremarkable medical history. Her pregnancy test is negative. Her Pap smear and STI panel are all 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?
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? What will be your expected results for the lab tests that you ordered to confirm your diagnosis?
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?
