Case Scenario 1
Table 1
In your own words include what type of screening (clinical breast exam, self breast exam, screening mammogram) is needed depending on the age and risk factor of the patient.
ACOG
ACS
USPSTF
Women
under age 40
Women aged
40-49 years
Women aged
50-74 years
Women aged
75 years and
older
Women with
dense breasts
As you can see each organization has different screening guidelines, it is best to
follow the protocols in your clinic for more guidance. Keep these guidelines in
mind when answering the case scenario.
Table 2
The American College of Radiology Breast Imagine Reporting and Data Systems
(BI-RADS)
Definition
BI-RADS 0
BI-RADS 1
BI-RADS 2
BI-RADS 3
BI-RADS 4
BI-RADS 5
BI-RADS 6
Madeline is a 41-year-old female who complains of a small lump she feels in her right breast. Upon physical examination, you palpate an approximately 2×2 cm firm, non-tender, immobile mass in the right upper outer quadrant of the right breast at approximately 10 oclock, 1 cm above the areola.
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?
b. Any other diagnosis or differential diagnosis you would like to add?
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.
