MINI SOAP NOTE PROMPT A 41-year-old female

MINI SOAP NOTE PROMPT A 41-year-old female is in the clinic to follow up on Pap results and she also reports a new palpable mass in her breast. It is approximately 1×1 cm mobile, tender, lump in her left breast that seems more noticeable just prior to and during menses. She uses a Copper T IUD x 5 years w/o problems with contraception. Her LMP was 3 weeks ago. She is G 2 P 2-both uncomplicated normal spontaneous vaginal deliveries. She’s been divorced x 6 years. Smokes tobacco 5 cigs/day since age 20, drinks 1-2 glasses of wine most nights, no drugs. Regular diet. VS WNL BMI 28.2 – Recent Pap result is ASCUS w/ +HPV To be completed in below format – make up information not given. complete in its entirety Subjective Data – HPI- complete for the patient matching her chief complaint. – Med History – make up answers for her – Think risk factors? Ask and make up answers for what risk factors could she have – Use OLDCART – Include ROS Objective Data – Include vital signs – Include point of care testing (POCT) (if appropriate) – Include an appropriate exam Assessment – Include ICD 10 code Plan Include medication (if appropriate) – Are there medications that may help someone with HPV? – Include education, teaching, follow up, and referral (if appropriate) – What is the plan for her? – USE ASCCP and USPSTF guidelines, please. Please reference. – You can also include what would be her follow up with her result was ASCUS

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