Assignment attached 

Gynacological question

PRAC 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

To prepare:

· Use the Focused SOAP Note Template found in the Learning Resources for this week to complete this Assignment.

· Select a patient that you examined during the last three weeks. With this patient in mind, address the following in your Focused Note Template.

Assignment

·
Subjective: What details did the patient provide regarding her personal and medical history?

·
Objective: What observations did you make during the physical assessment?

·
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

·
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.

·
Reflection notes: What would you do differently in a similar patient evaluation?

Patient is 24 year old female who comes in complaining of itching , gray vaginal discharge, it is thick and looks like cottage cheese . Symptoms started one week ago. No fever . No past medical history.