Case Scenario 2
Table 1
Definition and
how does this
test work
Pelvic UltrasoundAbdominal
Ultrasound
Pelvic UltrasoundTransvaginal
Ultrasound
Saline infusion
Sonohysterography
Hysteroscopy
HSGhysterosalpingogram
Laparoscopy
Endometrial Biopsy
(EMB)
Colposcopy
Endocervical
Curettage (ECC)
Dilation and
curettage (D&C)
What medical
conditions or
diagnoses are
best suited for
this test
Any special
considerations or
instructions prior to
or during the test
Donna is 35-year-old African American female who comes to the clinic
complaining of pelvic pain that started as intermittent, but now is almost
constant. She also complains of irregular vaginal bleeding/spotting that has
occurred in between her monthly menses for the last six months. She has no
family history of breast or ovarian cancer. Her vital signs (VS) and BMI are all
within normal limits (WNL), but upon physical examination, you palpate a firm,
raised area on her uterus. You note no cervical motion tenderness (CMT), no
adnexal tenderness (AT), and no other abnormalities. She is G2 P2 with both
normal spontaneous vaginal deliveries (NSVD) 10 and 8 years ago.
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? Which diagnostic test will
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 including any possible side effects
and/or considerations of the treatment.
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.