Description
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Case Scenario 1:
Complete the chart and answer the case scenario.
Birth
How it
% of
Combined
Contraindicated
Control
works/
effectiveness contraception for patients
frequency perfect use
VS Progestin with/ who are
of usage
VS typical
only method
use
Pill
Patch
NuvaRing
Annovera
DMPA
Implant
Paragard
LNG IUD
Denise, a 19-year-old female presents to the clinic for an annual physical
exam. She is G0P0, and presents with irregular menses only occurring every 34months apart within the past 2 years. She is sexually active and only using
condoms occasionally. She is not on any other birth control methods. She denies
any significant medical or surgical health history and denies any other current
health problems. She has never had a Pap smear or any pelvic exam tests before
today. Her pregnancy test is negative and her vital signs are all WNL.
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?
2. Objective:
a. What point of care testing (POCT) would you perform or order for
this patient?
b. Patient states she has not had a pap smear, is it appropriate to
perform a pap on this patient? Why or Why not?
3. Assessment/ Diagnosis:
a. What would be an appropriate diagnosis for her? Why?
b. Any other diagnosis or differential diagnosis you would like to add?
4. Plan:
a. What will you prescribe for this patient? Why?
b. What patient education is important to include for this patient?
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