SOAP Note

Review this weeks Learning Resources. Consider preventative health and assessing, diagnosing, and treating special populations.

Review the case study provided by your Instructor. Based on the provided patient information, think about the health history you would need to collect from the patient. 

Consider what physical exams and diagnostic tests would be appropriate in order to gather more information about the patients condition. Reflect on how the results would be used to make a diagnosis. 

Identify three to five possible conditions that may be considered in a differential diagnosis for the patient. 

Consider each patients diagnosis. Think about clinical guidelines that might support this diagnosis. 

Develop a preventative health treatment plan for the patient that includes health promotion and patient education strategies for special populations.

Complete:

Use the Focused SOAP Note Template to address the following:

Subjective: What details are provided regarding the patients personal and medical history?

Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial issues.

Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?

Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.

Reflection notes: Describe your aha! moments from analyzing this case.

Case study:

Marcia is a 28 year old female who comes in with a complaint of nipple drainage.  She says that the discharge started about three months ago and it appears milky.  She says that she has also felt tired, and has been constipated lately.  Her periods have been very light.  She is worried that she might have cancer.

•  What are the three classifications of nipple discharge? 

• Based on the above description, what classification does this fit into? 

• Aside from the above concerns, name three other things this woman may be experiencing. 

• Women with a strong family history of breast cancer may be candidates for genetic testing for __________ mutations. 

• You do a thorough breast examination on this pt.  What are two important components of this exam on anyone with nipple drainage? 

• You do a complete medication history as well as elicit past medical history, including endocrine and reproductive history.  What are four important parts of the exam on this pt and why?

• Name five chemical agents that can cause nipple discharge and galactorrhea.

•  What should the nipple discharge be tested for? 

• Why are cytologic studies not recommended? 

• Should diagnostic mammography be performed? 

• Following diagnostic mammography, what other imaging study might be performed and why? 

• What are two important lab tests to obtain? 

• When would an MRI of the brain be indicated? 

• Name three possible diagnoses for this patient. 

• If galactorrhea is suspected due as a result of a chemical origin, what must be done? 

• Galactorrhea is more common in _____________ (premenopausal/postmenopausal) women. 

• All patients with spontaneous or unilateral nipple discharge regardless of color, should be referred for surgical evaluation.

• Patients should be educated that most causes of breast discharge are malignant. 

• In women with galactorrhea, where the prolactin level is normal and menses are normal, women should be informed of the normal physiologic association with ______________________. 

•  Why is nipple discharge so concerning to most women?