Women’s health assessment and diagnosis
Tonia is an 18-year-old female who presents to your office complaining of two months of amenorrhea. Her pregnancy test is positive and her LMP indicates she is 5.6 weeks EGA. She reports she has had some bleeding for the past 3 days, that started as spotting but has continued to be a light period- like bleeding today. She denies any pain. She indicates plans to continue the pregnancy. Please include questions and patients answer 1. Subjective: a. What other relevant questions should you ask regarding the HPI? b. What other medical history questions should you ask? c. What other social history questions should you ask? 2. Objective: a. Describe all elements of the head-to-toe assessment you will perform for her initial prenatal visit b. Explain what test(s) you will order and perform and discuss your rationale for ordering and performing each test. 3. Assessment/ Diagnosis: a. What are your presumptive and differential diagnoses, and why? b. Any other diagnosis or differential diagnosis you would like to add? c. Assume you ordered an HCG today and the result was 1200. She returns to the clinic in 2 days and her HCG results is 550. What would be her diagnosis? 4. Plan: a. How will you explain the HCG results to your patient? b. Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s), partner notification, and follow-up plan of care. c. What patient education is important to include for this patient? (Consider when can the patient resume sexual activity, birth control options, when she can resume trying to conceive again). Provide evidence from the research to support your decision-making. Complete a SOAP note assessment after answering all the questions. Please explain your diagnosis and explain why you choose that diagnosis Here is a sample format of the DB SOAP note. Subjective CC: HPI: Medications: Allergies: LMP: Gyn/OB history: PMH: Chronic Illness/ Major trauma: Family Hx: Social Hx: ROS – List the body systems and provide answers – (Don’t forget to include Gyn ROS) – You can include questions here that you’d like to ask the patient Objective Data General- provide findings VS List body systems- provide findings – (Don’t forget Gyn System) – (You can include answers here to questions posed in the prompt) Include POCT (Point of Care testing) not labs that you will send to the laboratory Assessment/ Diagnosis Include the ICD10 code DDX Plan Diagnostic tests Lab Tests Treatment Medication Referrals Education Health Maintenance Follow up Soap note example make surge to include GYN system Demographic Data · Patient age and gender identity · MUST BE HIPAA compliant Subjective Chief Complaint (CC) · Place the complaint in Quotes · Brief description -only a few words and in the patient’s words · Example: “My chest hurts,” “I cannot breath,” or “I passed out,” etc. History of Present Illness (HPI) – the reason for the appointment today · Use the OLDCARTS acronym to document the Read More …