For this Case Study Discussion, you will propose a differential diagnosis with a minimum of 3 possible conditions or diseases. You will prioritize these diagnoses and explain which you would recommend.

Focused SOAP NOTE with the following:

· Differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.

· Define what you believe is the most important diagnosis. Be sure to include the first priority in conducting your assessment.

· Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.

Your differential diagnosis, what you believe the most important diagnosis is and why, additional diagnostic tests and treatments and rationales are what this assignment and grading is focused on. Your critical thinking for this assignment

References:

MUST BE SCHOLARY ( do not use WebMD, MAYO Clinic, Cleveland clinic, or any public website that are not scholarly)

Case Study: Obstetrics

Phillipa Hudson is a 29-year-old female presenting today at your clinic with a positive home pregnancy test. Her medical history is negative. Surgical history is negative. Gyn history 1st menses age 12, with cycles coming every 28 days and lasting for 5 days. Her pap and std history are negative. She has been taking a woman’s gummy vitamin for the past year. 

Her OB history is: 

See attachment #2.

  

Phillipa relates her last period (LMP) was 12-25-2022. She reports breast tenderness, fatigue,

and nausea (which is what made her suspect she was pregnant).

***Complete using attachment #1 for focused note***

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.

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For this Case Study Discussion, you will propose a differential diagnosis with a minimum of 3 possible conditions or diseases. You will prioritize these diagnoses and explain which you would recommend.

Focused SOAP NOTE with the following:

· Differential diagnosis (dx) with a minimum of 3 possible conditions or diseases.

· Define what you believe is the most important diagnosis. Be sure to include the first priority in conducting your assessment.

· Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning.

Your differential diagnosis, what you believe the most important diagnosis is and why, additional diagnostic tests and treatments and rationales are what this assignment and grading is focused on. Your critical thinking for this assignment

References:

MUST BE SCHOLARY ( do not use WebMD, MAYO Clinic, Cleveland clinic, or any public website that are not scholarly)

Case Study: Obstetrics

Phillipa Hudson is a 29-year-old female presenting today at your clinic with a positive home pregnancy test. Her medical history is negative. Surgical history is negative. Gyn history 1st menses age 12, with cycles coming every 28 days and lasting for 5 days. Her pap and std history are negative. She has been taking a woman’s gummy vitamin for the past year. Her OB history is: See attachment #2.

Phillipa relates her last period (LMP) was 12-25-2022. She reports breast tenderness, fatigue,

and nausea (which is what made her suspect she was pregnant).

***Complete using attachment #1 for focused note***

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