To prepare:

By Day 1 of this week, you will be assigned to a specific case study scenario for this Discussion. Please see the “Course Announcements” section of the classroom for your case study assignment from your Instructor.

Review the Learning Resources for this week and pay close attention to the media program related to the basic microscope skills. Also, consider re-reviewing the media programs found in Week 1 Learning Resources.

Carefully review the clinical guideline resources specific to your assigned case study.

 American College of Obstetricians and Gynecologists (ACOG)Links to an external site.. (2020).  https://www.acog.org/

American Nurses Association (ANA)Links to an external site.. (n.d.). https://www.nursingworld.org/

Centers for Disease Control and Prevention. (CDC)Links to an external site.. (n.d.). https://www.cdc.gov/

HealthyPeople 2030. (2020). Healthy People 2030 FrameworkLinks to an external site.. https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework

The American Association of Nurse Practitioners (AANP)Links to an external site.. What’s happening at your association. (2020). https://www.aanp.org/

Use the Focused SOAP Note Template attached to support Discussion. Complete a FOCUSED SOAP note and critically analyze this and focus your attention on the diagnostic tests. Please post your SOAP note. This will help you develop your differential diagnosis and additional questions.

Assignment:

Please post your FOCUSED SOAP NOTE with your differential diagnosis

Include the additional questions (additional questions ONLY related to the HPI/CC) you would ask the patient. Be sure to include an explanation of the tests you might recommend, ruling out any other issues or concerns and include your rationale. Be specific and provide examples.

Note: **Your differential diagnosis, additional questions, additional diagnostic tests and rationales are what this assignment and grading is focused on. Your critical thinking for this assignment

Case Study:

Elaine Goodwin is a 38-year-old G5 P5 LC 6 presenting to your clinic today to discuss contraceptive options.  She states that she is not interested in having more children but her new partner has never fathered a child. Her medical history is remarkable for exercise-induced asthma, migraines, and IBS. Her surgical history is remarkable only for tonsils as a child. Her social history is negative for alcohol, tobacco, and recreational drugs.  She has no known drug allergies and takes only vitamin C. Hospitalizations were only for childbirth. Family history reveals that her maternal grandmother is alive with dementia, while her maternal grandfather is alive with COPD. Her paternal grandparents are both deceased due to an automobile accident. Her mother is alive with osteopenia and fibromyalgia, and her dad is alive with a history of skin cancer (basal cell). Elaine has one older sister with no medical problems and one younger brother with no reported medical problems.  

· Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 P 68  

· HEENT:  wnl  

· Neck: supple without adenopathy  

· Lungs/CV: wnl  

· Breast: soft, fibrocystic changes bilaterally, without masses, dimpling or discharge  

· Abd: soft, +BS, no tenderness  

· VVBSU: wnl, except 1st degree cystocele  

· Cervix: firm, smooth, parous, without CMT  

· Uterus: RV, mobile, non-tender, approximately 10 cm,  

· Adnexa: without masses or tenderness 

  

NRNP 6552:
Advanced Nurse Practice in Reproductive Health Care

Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race


S.

CC (chief complaint): This is a
brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,”
not “bad headache for 3 days.”

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start
every HPI with age, race, and gender (e.g., 34-year-old African American female). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.

Allergies:
Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.

PMHx: Include immunization status (note date of
last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.

Soc & Substance Hx: Include occupation and major hobbies, family status, vaping, tobacco and alcohol use (previous and current use, how many times a day, how many years), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.

Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx:
Prior surgical procedures.

<