Case Study: Cervical Cytology Screening
Running head: CASE STUDY: CERVICAL CYTOLOGY SCREENING
Case Study: Cervical Cytology Screening
SOAP Note
6/29/17 9:30 am
Mrs. A is a pleasant, 35-year-old, white, female.
1
Case Study: Cervical Cytology Screening
2
Referral: none
Source and Reliability: Self, reliable source.
S (Subjective):
Chief complaint: “I need to have a pap test done.”
HPI: The patient presents today for annual pap smear screening, status post colposcopy. She
states that one year ago she had an abnormal pap smear, which was completed by her primary
care physician (PCP); Patient was referred to a gynecology (GYN) specialist for colposcopy.
Patient states that she had colposcopy completed and that the GYN scheduled her for a threemonth follow-up pap appointment and stressed the importance of completing the test. But, the
office had to reschedule the follow-up appointment three times, therefore, she has not had the
GYN exam. Patient is very worried that it has almost been a year since she had the colposcopy.
Allergies: NKA
Current Mediation: Multivitamin 1 tab PO daily, Chantix 1mg PO BID.
Childhood Illnesses. Chicken pox.
Adult Illnesses. Medical & Surgical: Atypical Squamous Cells of Undetermined Significance
(ASC-US) in June 2016. Colposcopy August 2016, negative. Psychiatric: None
Health Maintenance. Immunizations: Patient does not regularly receive annual flu vaccine.
Patient had a tetanus shot at an emergent care center in early 2015 because she stepped on metal
fragment and had to get stitches in her left foot. Screening tests: Does not see an
ophthalmologist and does not complain of vision problems. Patient has not visited the dentist in
over two years because she has no dental coverage with her insurance. Patient’s last PAP was
completed June 2016.
Family History: Mother – Breast and Cervical Cancer. Father – COPD from smoking.
Case Study: Cervical Cytology Screening
3
Social History: Patient has not smoked for 1 month. Previously she smoked ½ ppd for 10 years.
Patient drinks alcohol socially. She does not use illegal drugs. Patient lives in Orange County,
Florida and works at the local groceries store as a cashier. She is married without children.
Exercise & Diet: Patient reports no engagement in regular exercise. Safety Measures: Wears
seat belt.
ROS: ROS: Denies fevers, chills, fatigue, headache, weight gain or loss. Denies ear pain,
fullness, popping, loss of hearing, or drainage. Denies blurry vision, eye pain, itching, drainage,
or blindness. Denies nose drainage, loss of smell, allergies, or sinus pressure. Denies sore
throat, loss of taste, difficulty swallowing, tooth or gum pain and bleeding gums. Denies cough,
sputum, shortness of breath, and fatigue with exertion. Denies nausea, vomiting, abdominal
pain, constipation, melena, indigestion, reflux, dysphagia, diarrhea, and loss of appetite. Denies
dysuria, polyuria, hematuria, and nocturia, LMP 6/10/17, with menstruation lasting four (4) days,
normal flow for patient, no irregular periods or discharge. No breast tenderness, breast lumps,
nipple dimpling or discharge, no skin changes, patient reports regular completion of monthly self
breast exam. Denies chest pain, syncope, shortness of breath, palpitations, orthopnea, and ankle
edema. Denies mylagias, weakness, and joint pain. Denies rashes, new moles, and itching.
O (Objective)/Physical Exam
VS – BP: 122/79, HR: 73, RR: 16, Temp: 96.8, Weight: 157lbs, Height: 64inches, BMI: 27.
Mrs. A is alert and awake, and responding appropriately. Afebrile. Skin warm and dry, pink in
color, smooth, with good mobility and turgor. Multiple macules, flat, round, light brown in
color, measuring 1mm or less, scattered across bilateral arms, neck and face. Nails without
clubbing, cyanosis. Head. Hair of average texture, colored brown, thick, normal distribution, no
parasites or dandruff. Scalp without scales, lesions, lumps or nevi. Skull
Case Study: Cervical Cytology Screening
4
normocephalic/atraumatic. Facial expressions symmetrical, without involuntary movements,
edema, or masses. Eyes. Eyebrows full, evenly distributed, with moist underlying skin. Eyelids
resting normally on the iris, conjunctive pink, sclera white. Cornea, lens, and iris normal.
Lacrimal gland without swelling, not excessive tearing or dryness of eyes. Pupils 4mm
constricting to 2mm, equally round, and PERRLA. Optic disc margins sharp and clear,
yellowish in color. Retina normal without hemorrhages or exudates. Extraocular movements
intact, convergence normal (CN III, IV, VI). Visual fields full by confrontation. Ears: Auricle
without deformities, lumps, or skin lesions. No discharge, inflammation present. Bilateral canals
clear. TM with good cone of light, umbo and malleus visualized. Nose: Exterior midline,
symmetrical, without deformity. Mucosa pink, septum midline, inferior and middle turbinates
visualized. Internal nose without swelling, bleeding, exudates, ulcers, or polyps. No tenderness
of the frontal or maxillary sinuses. Mouth: Lips pink in color and moist, no lumps, ulcers,
cracking, or scaliness. Oral mucosa and interdental papillae pink without ulcers, patches, or
nodules. Dentition good, several filled cavities, none missing. Gums pink, without swelling or
ulceration. Tonsils present and of average size. Pharynx, hard and soft palate pink without
exudates. Hypoglossal nerve intact. Tongue midline and pink. Neck. Neck supple with full
ROM, midline and symmetrical, without masses, visual lymph nodes, or scars. Visible trachea
midline, without any deviation, noted. Thyroid and lobes not visualized or palpable. No cervical
or epitrochlear, adenopathy. No jugular venous distention. Thorax and Lungs. No cyanosis.
Breathing pattern non-labored and regular, without audible wheezes. Anteriorposterior:
transverse chest diameter ratio 1:2. Thorax is symmetrical with good expansion, both anterior
and posterior. No tenderness, lesions, masses, or sinus tracts noted upon palpation of anterior
and posterior chest. Lungs resonant in all fields. Breath sounds vesicular throughout; no rales,
Case Study: Cervical Cytology Screening
5
wheezes or rhonchi. Cardiovascular. Carotid upstrokes are brisk, without thrills or bruits. PMI
barely palpated in the left 5th intercostals space at the mid-clavicular line. No thrills, heaves, or
lifts detected upon palpation. Crisp S1 and S2, no S3 or S4. No murmurs or extra sounds
auscultated. Breasts. Medium size, symmetric, pink and smooth. No masses, dimpling, or
flattening. Nipples round and symmetrical, without discharge, rashes, or ulceration. Bilateral
axilla without rash, infection, or unusual pigmentation. No axillary lymphadenopathy.
Abdominal. Abdomen is flat and symmetrical. No scars, moles, strie, dilated veins, rashes,
lesions, peristalsis or pulsations visible. Umbilicus midline, without bulges. Active bowel
sounds in all four quadrants. No aortic, renal, iliac, or femoral bruits auscultated, no friction rubs
heard over the liver or spleen. Abdomen soft and non-tender to light and deep palpation. No
palpable masses or hepatosplenomegaly. Spleen and kidneys not felt. Aortic pulsations are
slightly palpable. Female Genitalia. Public hair present and without parasites. External
genitalia without erythema, lesions or masses. Vaginal mucosa pink. Cervix parous and pink,
without discharge, ulcerations, nodules, masses or bleeding. Uterus anterior, midline, smooth,
and not enlarged. Adenexa not palpated, no tenderness with attempted palpation. Pap smear
obtained.
A (Assessment)
Problem #1 – ASC-US one year ago on PAP smear. Today, follow-up PAP, status post
colposcopy.
Most Likely Diagnosis #1 – Positive/Abnormal PAP smear results
Differential Diagnosis:
-Atypical Glandular Cells (AGC)
-Atypical Squamous Cell (ASC)
Case Study: Cervical Cytology Screening
6
- Atypical Squamous Cells of Undetermined Significance (ASC-US)
-Atypical Squamous Cells Suspicious for High Grade Lesion (ASC-H)
-Cervical Carcinoma
-Endocervical adenocarcinoma in situ (AIS)
-Endometrial Cancer
-High Grade Squamous Intraepithelial Lesion (HSIL)
-Hyperkeratosis or Parakeratosis
-Low Grade Squamous Intraepithelial Lesion (LSIL)
-Reactive Changes due to Inflammation
-Adenocarcinoma
-Unsatisfactory for Evaluation
-Negative for Intraepithelial Lesion or Malignancy
P (Plan):
Testing: PAP Smear (Papanicolaou Smear)
Therapy/Treatment: To be determined by results of PAP smear.
Education: The pap smear exam is completed during the female pelvic exam. A sample is taken
from the inner and outer surface of the cervix and sent to the laboratory for microscopic exam of
the cells to be screened for pre-malignant lesions and cervical cancer. When a patient has a
negative pap smear result this indicates that the cervical cells were not at risk for the
development of cervical cancer at the time of the test. If the pap smear results return positive the
patient is at risk for cervical health issues, possibly cancer. Patient needs to be further evaluated
and tested. Over the past 30 years the pap smear has helped to decrease the incidence of cervical
cancer by greater then 50%. In order to continue to see the rate of cervical cancer decrease both
Case Study: Cervical Cytology Screening
7
practitioners and patients must work together to ensure that pap smear testing is being completed
annually, as recommended by the American College of Obstetricians and Gynecologists
(ACOG), or according to the patients age, risk group, and previous study results.
Follow-up: No follow-up needed at this time. The patient will be contacted with result of PAP
smear and the need for additional testing, if appropriate, when results are returned to the office.
Differential Diagnosis
Based on the above patient’s subjective and objective assessment, differential diagnoses
were determined. The patient presented for a routine gynecological exam. Patient had a history
of an abnormal pap smear, revealing ASC-US. The abnormal results called for advanced
interventions, including colposcopy. Therefore, differential diagnoses focused on the potential
results of the PAP smear that was collected during the pelvic exam. The first differential
diagnosis is a normal PAP exam, reported as “negative for intraepithelial lesion or malignancy”
(Clinical, 2015, p. 3). Another result of the pap screen could reveal that the specimen was
“unsatisfactory” for evaluation. This result can be due to the absence of cervical cells in the
specimen or the cytologist’s inability to complete the test because the cells are inflamed or
contaminated with blood. Epithelia abnormalities, including atypical squamous cell (ASC),
could also be reported as a result of the PAP, which would reveal that a small degree of nuclear
atypical was seen during microscopic examination. However, the severity was not ample to
warrant the diagnosis of squamous intraepithelial lesion. Furthermore, ASC can be divided into
two sub-categories including Atypical Squamous Cells of Undetermined Significance (ASC-US)
and Atypical Squamous Cells Suspicious for High Grade Lesion (ASC-H), which were both
included in the differential diagnosis. A fourth potential result/diagnosis of the pap is the
presence of atypical glandular cells (AGC). AGC designates glandular atypical cells which are
Case Study: Cervical Cytology Screening
8
identified in the cytology report as atypical endocervical cells, atypical endometrial cells
(possible endometrial cancer), or atypical glandular cells not otherwise specified. In addition,
AGC results can further identify endocervical adenocarcinoma or adenocarcinoma in situ (AIS).
Low Grade Squamous Intraepithelial Lesion (LSIL) is also reported as a result of pap testing,
indicating mild dysplasia consistent with HPV infections. In addition, High Grade Squamous
Intraepithelial Lesions (HSIL) can be found on pap examination which specify moderate or
severe dysplasia or carcinoma in situ (Cervical, 2014). Another result of the pap could reveal
Hyperkeratosis or Parakeratosis which is associated with trauma or infection of the cervix
(Penson, 2013). Finally, Cervical Carcinoma or Squamous Cell Carcinoma can be reported as a
result of PAP testing (Cervical, 2015). Overall, all the potential results of pap testing were
including the differential diagnosis and the working diagnosis will be given when the result of
the patient’s pap test is returned from the laboratory.
Orders
Liquid based cervical cytology was utilized for pap screening during the pelvic
examination. The liquid based technique, which 90% of obstetricians and gynecologist utilize,
allows the practitioner to collect exfoliated cells form the transformation zone of the cervix and
transfer them to a “vial of liquid preservative that is processed in the laboratory to produce a
slide for interpretation” (Cervical, 2015, p. 2). Utilization of the liquid based test has decreased
the number of rejected tests due to blood, discharge, inflammatory cells, and lubricant
contamination because of its unique ability to filter out the debris (Cervical, 2015). In addition,
“prompt suspension of the cells in the liquid eliminates the problem of air drying artifact”
(Cervical, 2015, p. 2). The liquid based method also allows the practitioner to test for gonorrhea
and chlamydia infections in addition to the HPV testing. Moreover, cytologists report that liquid
Case Study: Cervical Cytology Screening
9
based tests are simple to interpret. But, while there are numerous advantages to using liquid
based cytology collection for pap testing, as compared to the conventional method, there are also
a few disadvantages. Liquid based test are more expensive to collect than the conventional test
and have demonstrated decreased sensitivity specificity for diagnosing atypical cells (Cervical,
2015). Overall, the cervical cytology screening guideline states that “both liquid-based and
conventional methods of cervical cytology are acceptable for screening” (Cervical, 2015, p. 8).
Identify the First and Second Line Treatment
The clinical practice guidelines for the management of women with abnormal cervical
cancer screening tests, published by the American Society for Colposcopy and Cervical
Pathology (ASCCP), identify specific treatment measures for patients with cervical cytology
results of ASC-US. The guideline states that for women over twenty years of age there are three
acceptable ways to initially manage patient care when pap cytology results return as ASC-US.
The first approach is to repeat the cytology results at six and twelve months. If both tests are
negative the patient can return to the routine screening methods, based on their history of ASCUS. But, if any form of atypical squamous cells are found on either cytology test colposcopy is
recommended to provide a more detailed examination of the cervical cells. The second suitable
way to manage ASC-US is to complete “reflex” human papaloma virus (HPV) testing with liquid
based cytology. This approach is normally chosen for post-menopausal woman because the
incidence of ASC-US and HPV in this particular population is very low (Management, 2014;
National, 2014). Therefore, HPV testing “is more efficient in older women because it refers a
lower proportion of these women to colposcopy” (Management, 2014, p. 6). If testing results are
negative for HPV than repeat cytology is recommended in twelve months. On the other hand, if
the HPV test is positive colposcopy should be performed. Consequently, the third acceptable
Case Study: Cervical Cytology Screening 10
method of managing patients with ASC-US is colposcopy, the exam that is completed if either of
the first two option tests return positive. For example, if the repeat cytology is positive or the
HPV DNA testing is positive, colposcopy is recommended. If colposcopy results return positive
for cervical intraepithelial neoplasia (CIN) management must shift to the specific CIN treatment
recommendations provided in the ASCCP guideline. But, if colposcopy results return negative
for CIN and the patient’s HPV status is unknown a repeat cytology should be completed in
twelve months. On the other hand, if the patient had a history of high risk types of HPV and had
previously tested positive for HPV the practitioner could repeat cytology in six and twelve
months or complete HPV DNA testing in twelve months. If the repeat cytology either at six or
twelve months reveals abnormal cells for HPV repeat colposcopy is suggested. But if both
cytology exams return negative, or when you have two negative tests in a row, the patient can
return to a routine cytology screening schedule. Furthermore, if the practitioner decides to wait
to perform HPV DNA testing at twelve months and it returns negative then the patient can return
to routine screening, with history of ASC-US and HPV (Management, 2014; National, 2014).
Overall, the practitioner selects the appropriate evidenced based management plan out of the
three presented in the ASCCP guideline to create the best care plan for the patient based on their
history and physical.
The clinical practice guidelines for the management of women with abnormal cervical
cancer screening tests was created in 2006 and last reviewed in 2009. The guideline was
developed and funded by the Medical Specialty Society of the American Society of Colposcopy
and Cervical Pathology. Specific details on guideline committee formation, meetings, and
composition methods for the guideline were not disclosed. In addition, financial disclosures and
Case Study: Cervical Cytology Screening 11
conflicts of interest were not stated in the guideline. On the other hand, authors of the guideline
were recognized (National, 2014). Primary authors included:
Thomas C. Wright Jr, MD, Department of Pathology, College of Physicians and
Surgeons of Columbia University, New York, NY; L. Stewart Massad, MD Department
of Obstetrics and Gynecology, Washington University School of Medicine, St Louis,
MO; Charles H. Dunton, MD, Department of Obstetrics and Gynecology, Lankenau
Hospital, Wynnewood, PA; Mark Spitzer, MD, Department of Obstetrics and
Gynecology, Brookdale University Hospital and Medical Center, Brooklyn, NY; Edward
J. Wilkinson, MD, Department of Pathology, University of Florida College of Medicine,
Gainesville, FL; Diane Solomon, MD, National Institutes of Health and National Cancer
Institute, Bethesda, MD (National, 2009, p. 14).
Prior to publication the guideline was reviewed by numerous professional practice organizations
including the American Society of Family Physicians, American Cancer Society, American
Society for Clinical Pathology, American Society for Colposcopy and Cervical Pathology,
Center for Disease Control and Prevention, and numerous other International Societies, among
others (National, 2014). Overall, the guideline was authored by many experts in the fields of
women’s health and pathology and is supported by numerous professional organizations, which
supports its content and application to medical practice. In conclusion, it is imperative that
practitioners follow the clinical practice guidelines for the management of women with abnormal
cervical cancer screening presented by ASCCP according to the patient’s individual presentation
to ensure the best possible patient outcomes.
Epidemiology
Case Study: Cervical Cytology Screening 12
The incidence of cervical cancer has significantly decreased over the past decade due to
increased cervical cancer screening initiatives with PAP smear testing. In 2007 the incidence of
cervical cancer in the United States (U.S.) among women was 7.8 per 100,000 as compared to
6.4 per 100,000 in Maryland. More specifically, in Caroline County, MD where the patient in
the presented SOAP note resides there were no reported cases of cervical cancer. However, in
2007 both the U.S. and Maryland cervical cancer mortality rate was 2.4 per 100,000 women
(Poppell, King, Groves, Dwyer, Sage, & Hussein, 2015). Therefore, these statistics indicate that
women in Maryland who are diagnosed with cervical caner are either not being treat being
treated appropriately or are being diagnosed to late in the disease process to prevent mortality.
“In 2007, 38.1% of all cervical cancer cases in Maryland were diagnosed at the localized stage,
34.5 were diagnosed at the regional stage, and 16% were found at the distant stage” (Poppell, et
al., 2015, p. 119). One of the Healthy People 2010 goals for cervical cancer screening across the
U.S. is to have 90% of women age 18 years report PAP testing within the past three years. In
2002 Maryland hit the 92 percentiles for this particular Healthy People 2010 goal, but has
decreased in percentage every year since landing at 84% in 2008 (Poppell, et al., 2015). It is
imperative that Maryland examine and plan to break down the current barriers that are impinging
them from providing the preventative measures needed, as identified in the current practice
guidelines, to diagnose and treat, thus decrease the mortality rate of cervical cancer.
Preventative Treatment
There are numerous preventative treatment measures that can be taken against cervical
cancer that practitioners should share with their female patients of all ages. Adolescent patients
should be educated that certain activities including abstinence from smoking, second hand
smoke, and sexual activity will minimize their risk of contracting a HPV infection which is
Case Study: Cervical Cytology Screening 13
directly related to cervical cancer. For patients ages 9-26 year’s vaccination against HPV, the
etiologic agent of cervical cancer, is recommended. When patients are sexually active,
preventative measures include the utilization of barrier protection and/or spermicidal gel during
sexual intercourse, is recommended. In addition, women should be informed that high parity is
also associated with an increased risk of cervical cancer (Poppell, et al., 2015). Finally,
“screening of appropriate women via regular gynecologic examinations and cytology test (pap
test, either conventional or liquid-based cytology), with treatment of precancerous abnormalities,
reduces the mortality from cervical cancer” (Poppell, et al., 2015, p. 121). Pap testing should
begin at age 21 if the patient is not sexually active. When adolescents are sexually active prior to
the age of 21 pap screening should be completed three years after onset of sexual activity or at
age 21, which ever comes first (Cervical, 2009; Poppell, et al., 2015). Between the ages of 21
and 20 pap cervical cytology is recommended every 2 years, if all testing results are normal
(Cervical, 2015). “Women aged 30 years and older who have had three consecutive negative
cervical cytology screening test results and who have no history of CIN2 or CIN3, are not HIV
infected, are not immunocompromised, and were not exposed to diethylstilbestrol in utero my
extend the interval between examination to every 3 years” (Cervical, 2015, p. 8). Women with a
history of abnormal pap or an unknown cervical screening history are at risk for development of
cervical caner for 20 years and should have annual cytology testing completed (Cervical, 2015).
Cervical cancer screening can be discontinued for patients between 65 and 70 years of age who
have had “three or more negative cytology test results in a row and no abnormal test results in
the past 10 years” (Cervical, 2015, p. 8). Cytology testing can be discontinued for patients who
have undergone hysterectomy for benign diagnoses. On the other hand, pap screening of the
vaginal cuff should be continued for women who have had hysterectomies secondary to
Case Study: Cervical Cytology Screening 14
abnormal cells and/or cancer (Cervical, 2015). Overall, it is imperative that practitioners follow
the latest evidenced based guidelines for cervical cytology screening in order to diagnose and
treat abnormal cervical cells, thus decreasing the incidence and mortality of women with cervical
cancer both locally and globally.
Prescribed Management Comparison
The standard of care management approach for abnormal cervical cytology screening,
focusing on ASC-US, differed slightly from the prescribed management plan presented in the
SOAP note. In June 2016, the patient had a pap completed revealing ASC-US cytology results.
A referral was then made to a GYN for the abnormal results. The GYN decided to complete a
colposcopy during August 2010, which is one of the three acceptable first line management tests
for patients with ASC-US. The results of the colposcopy were negative for CIN and since the
patient’s HPV status was unknown repeat cytology was ordered. The difference in the
prescribed management plan arose when the GYN prescribed repeat cytology in three months
and not in one year as proposed in the clinical practice guideline. But, due to numerous
circumstances the patient did not have the repeat cytology completed until one year later, as the
guideline recommends. In the end, the patient received proper management for her diagnosis
according to the guidelines. An evidenced based plan of care will be created when the cytology
results from her current exam return.
Case Study: Cervical Cytology Screening 15
References
Arcangelo, V.P. & Peterson, A.M. (2015). Pharmacotherapeutics for advanced practice: A
practical approach (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.
Bickley, L. S. (2009). Bates’ pocket guide to physical examination and history taking (6th ed.).
Philadelphia: Lippincott Williams & Wilkins.
Clinical Management Guidelines for Obstetrician-Gynecologists. (2015, December). Cervical
cytology screening. The American College of Obstetricians and Gynecologists Women’s
Health Care Physicians. Washington, DC.
Clinical Management Guidelines for Obstetrician-Gynecologists. (2014, December).
Management of abnormal cervical cytology and histology. The American College of
Obstetricians and Gynecologists Women’s Health Care Physicians. Washington, DC.
Domino, F. J. (Eds.). (2015). The 5-minute clinical consult. Philadelphia: Lippincott Williams &
Wilkins.
National Guideline Clearinghouse. (2014). 2006 consensus guideline for the management of
women with abnormal cervical cancer screening tests. U.S. Department of Health and
Human Services. Retrieved July 4, 2017, from http://www.guideline.gov/content.aspx?
Id=14698&search=american+society+for+colposcopy+and+cervical+pathology
Penson, T. T. (2015, June 21). Abnormal pap smear. Epocrates, Inc. Retrieved
July 4, 2017 from http://online.epocrates.com/noFrame/showPage.do?method
=disease&MonographId=1123&ActiveSectionId=22
Poppell, C. F., King, M., Groves, C., Dwyer, D. M., Sage, K., & Hussein, C. A. (2015, July.
Cancer report 2017 revised. Maryland Department of Health and Mental Hygiene.
Baltimore, MD.
SOAP NOTE TEMPLATE
Please include a heart exam and lung exam on all clients regardless of the reason for seeking
care. So, if someone presented with vaginal discharge, you would examine the General
appearance, Heart and Lungs, abdomen and pelvis for a focused/episodic exam. The pertinent
positive and negative findings should be relevant to the chief complaint and health history data.
This template is a great example of information documented in a real chart in clinical practice.
The only section that will not be included in a real chart is differential diagnosis. The term “Rule
Out…” cannot be used as a diagnosis.
Subjective Data (20 pts.)
Chief Complaint (CC):
History of Present Illness (HPI):
Last Menstrual Period (LMP)
Allergies:
Past Medical History:
Family History:
Surgery History:
Obstetrical/GYN History:
Social History (alcohol, drug, or tobacco use):
Current medications:
Review of Systems (Remember to inquire about body systems relevant to the chief complaint
and HPI)
Objective Data (25 pts.)
Please remember to include an assessment of all relevant systems based on the CC and
HPI.
Vital Signs/ Height/Weight:
General Appearance:
Assessment (20 pts.)
A: Differential Diagnosis
Please rule out all differential diagnosis with subjective and objective data and/or lab-work.
Provide references.
1.
2.
3.
B: Medical Diagnosis
Rule in diagnosis with subjective and objective data and lab-work. Please explain how you arrived
at the diagnosis. Provide references.
1.
PLAN (25 pts.)
A: Orders
1.
2.
3.
4.
5.
6.
Prescriptions with dosage, route, duration, amount prescribed, and if refills are provided
Diagnostic testing needed
Problem oriented education
Interpersonal/Social support/communication
Age appropriate Health Promotion/Maintenance/Screening Needs
Referrals and follow up with rationales
Cultural Diversity: What cultural considerations would you suggest for this patient?
Patient/Family Education: If patient is currently on any medications, please address if
you want them to discontinue or continue. You always want this to be clear at the end of
the visit.
B: Follow-Up Plans (When will you schedule a follow-up appointment and what will you address
in the subsequent visit ---F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic) with
rationales
APA Format (10 pts.)
Include a title page and references with all of your papers. There should be at least four
references from textbooks, journal articles, CDC or NIH that are not older than 5 years. Please
do not use Wikipedia, WebMD, dictionaries, or any websites that are not evidence based.
Purchase answer to see full
attachment