Complete all the requirements of the case scenario.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.

Create a soap note in detailed; make things up to complete the soap note that make sense and is relevan
Case Scenario 2
Table 1
Definition
Presentation/
Sign and
Symptoms
Management
Mastalgia
Mastitis
Nipple Discharge
Breast Mass
Nipple Changes
Table 2
Diagnostic test
Screening
Mammogram
Diagnostic
Mammogram
Breast Ultrasound
MRI of the Breast
Biopsy (FNA and
CNB)
How is this test helpful in breast conditions
Surgical Biopsy
Natalie is a 31-year-old G0 P0 female who complains of intermittent breast
pain. She thinks she feels lumps in the outer quadrants of her breasts but is
unsure of the location today. She has no family or personal history of cancers, she
menstruates regularly, is not pregnant, and uses condoms consistently for BCM
and STI protection.
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. Include
the steps in assessment of mastalgia.
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?
c. What information is most important in determining whether this is a
potentially serious or benign issue?
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.