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

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 o’clock, 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.