- Think about the details of the patient’s background, medical history, physical eval, labs and diagnostics, diagnosis, and treatment and management plan, and education strategies and follow-up care.
- What additional considerations might you think about if your patient was pregnant or just delivered?
- Use the “Guidelines for Comprehensive History and Physical SOAP Note” document found in this week’s Learning Resources to guide you as you complete this Assignment.
Assignment:
Write an 8- to 10-page Comprehensive Well-Woman eval that addresses the following:
· Age, race and ethnicity, and partner status of the patient
· Current health status, including chief concern or complaint of the patient
· Contraception method (if any)
· Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)
· Review of systems
· Physical assessment
· Labs, and other diagnostics
· Differential diagnoses
· Management plan, including diagnosis, treatment, patient education, and follow-up care
· Provide evidence-based guidelines to support treatment plan.
Note: Use your Learning Resources and evidence from scholarly sources from your personal search to support your treatment plan of care.
Reflection
Reflect on some additional factors for your patient:
· What are the implications if your patient was pregnant or just delivered?
· What are implications if you have observed or know of some domestic violence? Would this change your plan of care? If so, how?
Use your Learning Resources and evidence from scholarly sources from your personal search to support your reflection.
PRAC 6552:
Advanced Nurse Practice in Reproductive Health Care Practicum
Guidelines for a Comprehensive History and Physical SOAP Note
Label each section of the SOAP note (each body part and system).
Do
not use unnecessary words or complete sentences.
Use standard abbreviations.
SUBJECTIVE DATA (S):
(information the patient/caregiver tells you)
Includes all of the information the patient tells you. Identifying data: Initials, age, race, gender, marital status. Name of informant, if not patient.
CHIEF COMPLAINT (CC): The reason for this health care visit. A statement describing the symptom(s), problem, condition, diagnosis, physician-recommended return, or other factors that are the reason for this patient visit (even if they bring no specific problem). If possible, use the patient’s own words in quotation marks.
HISTORY OF PRESENT ILLNESS (HPI): If the patient presents with specific problems, symptoms, or complaints, a chronological description of the development of the patient’s present illness from the first sign of each symptom to the current visit is recorded using the elements of
a symptom analysis. Those elements are:
·
Location: Where it started, where it is located now
·
Quality: Unique properties or characteristics of the symptom
·
Severity: Intensity, quantity, or impact on life activities; duration: length of episode
·
Timing: When symptom started, frequency (patient’s “story” of the symptom), context (under what conditions it occurs)
·
Setting: Under what conditions the symptoms occur, activities that produce the symptoms
·
Alleviating and aggravating factors: What makes it better and/or worse, what meds have been taken to relieve symptoms, did the meds help or not, does food make symptoms worse or better
·
Associated signs and symptoms: Presence or absence of other symptoms or problems occurring with their complaint; include pertinent negatives and information from the patient’s charts (e.g., lab data or previous visit information)
In the case of a
well visit, describe the patient’s usual health and summarize health maintenance needs and activities.
PAST MEDICAL HISTORY (PMH):
· Allergies
· Current medications: prescription and over the counter
· Age/health status
· Appropriat
Alexis Tuero
Miami Regional University
Date of Encounter: 9/8/21
Preceptor/Clinical Site: Taymi Rodriguez
Clinical Instructor: Emelio Garcia
Soap Note # 1 Vulvovaginal Candidiasis
PATIENT INFORMATION
Name: DC
Age: 40 years
Gender at Birth: Female
Gender Identity: Woman
Source: DC
Allergies: Reports of no known food or drug allergies.
Current Medications: Metformin
PMH: She reports that she is a known diabetic. She reports of a history of hospitalizations ten years ago after she was diagnosed with the condition. She reports that she was diagnosed with diabetes type 2 and it was medically controlled.
Immunizations: Reports of updated immunizations according to schedule.
Preventive Care: She reports that she has been exercising and feeding on a diabetic diet to control the glycemic levels. She also reports that she has been attending all appointments and adhering to the medications. She also reports that she has been following the COVID-19 prevention protocol.
Surgical History: She reports of a history of tubal ligation.
Family History: She reports that she is a mother to two children who are healthy and well. She also reports that her mother died of diabetic ketoacidosis and father died of a stroke.
Social History: she reports that she is a university graduate. She works as a secretary in the Miami state office. She also reports that she has been married for 12 years, blessed with two children and lives with her husband. She reports that she was an alcoholic but she has quit. She denies of cigarette smoking or abuse of drug substances.
Sexual Orientation: Heterosexual, she is married and lives with her husband.
Nutrition History: she reports that she feeds on a highly nutritious balanced diet that contains plenty vegetables and fruits. She also reports that she avoids foods that are high in cholesterol, soft drinks and foods that she was advised against eating.
Subjective Data:
Chief Complaint: “I have a thick white vaginal discharge and vaginal soreness”
Symptom analysis/HPI:
DC is a 40-year-old female who presents to the physician’s office with chief complains of whitish discharge from the vagina. She reports that the discharge is thick and is odor-free and that it started about three days ago. She reports that the discharge was initially watery but it changed into whitish and became thick. She also reports that she has been
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