Gynecologic Health

Select a patient that you examined as a nurse practitioner student during the last three weeks of clinical on OB/GYN Issue. With this patient in mind, address the following in a SOAP Note 1 OR 2 PAGES :

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 for this patient , as well as a rationale for this treatment and management plan.

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

Reference

Gagan, M. J. (2009). The SOAP format enhances communication. Kai Tiaki Nursing New Zealand, 15(5), 15.

Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & Women’s health (4th ed.). Burlington, MA: Jones & Bartlett Publishers.

Chapter 6, “Care of the Well Woman Across the Life Span” ,“Care of the Woman Interested in Barrier Methods of Birth Control” (pp. 275–278)

Chapter 7, “Care of the Woman with Reproductive Health Problems”

“Care of the Woman with Dysmenorrhea” (pp. 366–368) 

“Care of the Woman with Premenstrual Symptoms, Syndrome (PMS), or Dysphoric Disorder (PMDD)” (pp. 414–418)

Sample Solution

SOAP Note for Gynecologic Health Assessment

Subjective:

The patient is a 25-year-old female who presented to the clinic with a complaint of lower abdominal pain for the last two weeks. She reports that the pain started after her menstrual cycle and has been continuous since then. She denies any nausea, vomiting, or fever. The patient reports regular menstrual cycles with moderate bleeding and no use of contraceptives. Her past medical history is unremarkable, and she has no known allergies to medications.

Objective:

On physical examination, vital signs were stable, and abdominal examination revealed tenderness in the lower abdomen without any guarding or rebound tenderness. Pelvic examination showed no abnormalities in the external genitalia. Vaginal speculum exam revealed a moderate amount of clear discharge with no foul odor. Bimanual exam showed a tender uterus, without any palpable masses.

Assessment:

Differential diagnoses for the patient’s symptoms include:

1. Pelvic inflammatory disease (PID)
2. Endometriosis
3. Ovarian…NEED A COMPREHENSIVE ANSWER? POST YOUR ORDER