Soap note to presents GYN problem or OB case and subjective data, health & medical homework help

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Presentation of Case and Subjective Data

Clearly and thoroughly presents GYN problem or OB case and subjective data.

Objective Data

Clearly and thoroughly presents objective data. All of the relevant systems addressed based on the CC and HPI.

Assessment

Correct differential and medical diagnosis.

Plan

Correct plan of care for each issue. Thoroughly addressed (diagnostic studies, meds, education social and personal responses, health promotion/screening by age, ethical and cultural considerations, follow up, referrals). All components addressed.

Organization and Writing.

SOAP note/plan of care was thoroughly organized and well-written. All ideas were stated clearly and logically.

Writes relevant content.

Project was thoroughly on topic and relevant.

Formatting, spelling and grammar.

All formatting guidelines followed and template was used. No spelling or grammatical errors.

SOAP NOTE TEMPLATE

Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with vaginal discharge, you would examine the General appearance, Heart and Lungs, abdomen and pelvis for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice. The only section that will not be included in a real chart is differential diagnosis. The term “Rule Out…” cannot be used as a diagnosis.

Subjective Data (20 pts.)

Chief Complaint (CC):

History of Present Illness (HPI):

Last Menstrual Period (LMP)

Allergies:

Past Medical History:

Family History:

Surgery History:

Obstetrical/GYN History:

Social History (alcohol, drug, or tobacco use):

Current medications:

Review of Systems (Remember to inquire about body systems relevant to the chief complaint and HPI)

Objective Data (25 pts.)

Please remember to include an assessment of all relevant systems based on the CC and HPI.

Vital Signs/ Height/Weight:

General Appearance:

Assessment (20 pts.)

A: Differential Diagnosis

Please rule out all differential diagnosis with subjective and objective data and/or lab-work. Provide references.

1.

2.

3.

B: Medical Diagnosis

Rule in diagnosis with subjective and objective data and lab-work. Please explain how you arrived at the diagnosis. Provide references.

1.

PLAN (25 pts.)

A: Orders

1.Prescriptions with dosage, route, duration, amount prescribed, and if refills are provided

2.Diagnostic testing needed

3.Problem oriented education

4.Interpersonal/Social support/communication

5.Age appropriate Health Promotion/Maintenance/Screening Needs

6.Referrals and follow up with rationales

Cultural Diversity: What cultural considerations would you suggest for this patient?

Patient/Family Education: If patient is currently on any medications, please address if you want them to discontinue or continue. You always want this to be clear at the end of the visit.

B: Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit ---F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic) with rationales

APA Format (10 pts.)

Include a title page and references with all of your papers. There should be at least four references from textbooks, journal articles, CDC or NIH that are not older than 5 years. Please do not use Wikipedia, WebMD, dictionaries, or any websites that are not evidence based.

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Case Study: Cervical Cytology Screening Running head: CASE STUDY: CERVICAL CYTOLOGY SCREENING Case Study: Cervical Cytology Screening SOAP Note 6/29/17 9:30 am Mrs. A is a pleasant, 35-year-old, white, female. 1 Case Study: Cervical Cytology Screening 2 Referral: none Source and Reliability: Self, reliable source. S (Subjective): Chief complaint: “I need to have a pap test done.” HPI: The patient presents today for annual pap smear screening, status post colposcopy. She states that one year ago she had an abnormal pap smear, which was completed by her primary care physician (PCP); Patient was referred to a gynecology (GYN) specialist for colposcopy. Patient states that she had colposcopy completed and that the GYN scheduled her for a threemonth follow-up pap appointment and stressed the importance of completing the test. But, the office had to reschedule the follow-up appointment three times, therefore, she has not had the GYN exam. Patient is very worried that it has almost been a year since she had the colposcopy. Allergies: NKA Current Mediation: Multivitamin 1 tab PO daily, Chantix 1mg PO BID. Childhood Illnesses. Chicken pox. Adult Illnesses. Medical & Surgical: Atypical Squamous Cells of Undetermined Significance (ASC-US) in June 2016. Colposcopy August 2016, negative. Psychiatric: None Health Maintenance. Immunizations: Patient does not regularly receive annual flu vaccine. Patient had a tetanus shot at an emergent care center in early 2015 because she stepped on metal fragment and had to get stitches in her left foot. Screening tests: Does not see an ophthalmologist and does not complain of vision problems. Patient has not visited the dentist in over two years because she has no dental coverage with her insurance. Patient’s last PAP was completed June 2016. Family History: Mother – Breast and Cervical Cancer. Father – COPD from smoking. Case Study: Cervical Cytology Screening 3 Social History: Patient has not smoked for 1 month. Previously she smoked ½ ppd for 10 years. Patient drinks alcohol socially. She does not use illegal drugs. Patient lives in Orange County, Florida and works at the local groceries store as a cashier. She is married without children. Exercise & Diet: Patient reports no engagement in regular exercise. Safety Measures: Wears seat belt. ROS: ROS: Denies fevers, chills, fatigue, headache, weight gain or loss. Denies ear pain, fullness, popping, loss of hearing, or drainage. Denies blurry vision, eye pain, itching, drainage, or blindness. Denies nose drainage, loss of smell, allergies, or sinus pressure. Denies sore throat, loss of taste, difficulty swallowing, tooth or gum pain and bleeding gums. Denies cough, sputum, shortness of breath, and fatigue with exertion. Denies nausea, vomiting, abdominal pain, constipation, melena, indigestion, reflux, dysphagia, diarrhea, and loss of appetite. Denies dysuria, polyuria, hematuria, and nocturia, LMP 6/10/17, with menstruation lasting four (4) days, normal flow for patient, no irregular periods or discharge. No breast tenderness, breast lumps, nipple dimpling or discharge, no skin changes, patient reports regular completion of monthly self breast exam. Denies chest pain, syncope, shortness of breath, palpitations, orthopnea, and ankle edema. Denies mylagias, weakness, and joint pain. Denies rashes, new moles, and itching. O (Objective)/Physical Exam VS – BP: 122/79, HR: 73, RR: 16, Temp: 96.8, Weight: 157lbs, Height: 64inches, BMI: 27. Mrs. A is alert and awake, and responding appropriately. Afebrile. Skin warm and dry, pink in color, smooth, with good mobility and turgor. Multiple macules, flat, round, light brown in color, measuring 1mm or less, scattered across bilateral arms, neck and face. Nails without clubbing, cyanosis. Head. Hair of average texture, colored brown, thick, normal distribution, no parasites or dandruff. Scalp without scales, lesions, lumps or nevi. Skull Case Study: Cervical Cytology Screening 4 normocephalic/atraumatic. Facial expressions symmetrical, without involuntary movements, edema, or masses. Eyes. Eyebrows full, evenly distributed, with moist underlying skin. Eyelids resting normally on the iris, conjunctive pink, sclera white. Cornea, lens, and iris normal. Lacrimal gland without swelling, not excessive tearing or dryness of eyes. Pupils 4mm constricting to 2mm, equally round, and PERRLA. Optic disc margins sharp and clear, yellowish in color. Retina normal without hemorrhages or exudates. Extraocular movements intact, convergence normal (CN III, IV, VI). Visual fields full by confrontation. Ears: Auricle without deformities, lumps, or skin lesions. No discharge, inflammation present. Bilateral canals clear. TM with good cone of light, umbo and malleus visualized. Nose: Exterior midline, symmetrical, without deformity. Mucosa pink, septum midline, inferior and middle turbinates visualized. Internal nose without swelling, bleeding, exudates, ulcers, or polyps. No tenderness of the frontal or maxillary sinuses. Mouth: Lips pink in color and moist, no lumps, ulcers, cracking, or scaliness. Oral mucosa and interdental papillae pink without ulcers, patches, or nodules. Dentition good, several filled cavities, none missing. Gums pink, without swelling or ulceration. Tonsils present and of average size. Pharynx, hard and soft palate pink without exudates. Hypoglossal nerve intact. Tongue midline and pink. Neck. Neck supple with full ROM, midline and symmetrical, without masses, visual lymph nodes, or scars. Visible trachea midline, without any deviation, noted. Thyroid and lobes not visualized or palpable. No cervical or epitrochlear, adenopathy. No jugular venous distention. Thorax and Lungs. No cyanosis. Breathing pattern non-labored and regular, without audible wheezes. Anteriorposterior: transverse chest diameter ratio 1:2. Thorax is symmetrical with good expansion, both anterior and posterior. No tenderness, lesions, masses, or sinus tracts noted upon palpation of anterior and posterior chest. Lungs resonant in all fields. Breath sounds vesicular throughout; no rales, Case Study: Cervical Cytology Screening 5 wheezes or rhonchi. Cardiovascular. Carotid upstrokes are brisk, without thrills or bruits. PMI barely palpated in the left 5th intercostals space at the mid-clavicular line. No thrills, heaves, or lifts detected upon palpation. Crisp S1 and S2, no S3 or S4. No murmurs or extra sounds auscultated. Breasts. Medium size, symmetric, pink and smooth. No masses, dimpling, or flattening. Nipples round and symmetrical, without discharge, rashes, or ulceration. Bilateral axilla without rash, infection, or unusual pigmentation. No axillary lymphadenopathy. Abdominal. Abdomen is flat and symmetrical. No scars, moles, strie, dilated veins, rashes, lesions, peristalsis or pulsations visible. Umbilicus midline, without bulges. Active bowel sounds in all four quadrants. No aortic, renal, iliac, or femoral bruits auscultated, no friction rubs heard over the liver or spleen. Abdomen soft and non-tender to light and deep palpation. No palpable masses or hepatosplenomegaly. Spleen and kidneys not felt. Aortic pulsations are slightly palpable. Female Genitalia. Public hair present and without parasites. External genitalia without erythema, lesions or masses. Vaginal mucosa pink. Cervix parous and pink, without discharge, ulcerations, nodules, masses or bleeding. Uterus anterior, midline, smooth, and not enlarged. Adenexa not palpated, no tenderness with attempted palpation. Pap smear obtained. A (Assessment) Problem #1 – ASC-US one year ago on PAP smear. Today, follow-up PAP, status post colposcopy. Most Likely Diagnosis #1 – Positive/Abnormal PAP smear results Differential Diagnosis: -Atypical Glandular Cells (AGC) -Atypical Squamous Cell (ASC) Case Study: Cervical Cytology Screening 6 - Atypical Squamous Cells of Undetermined Significance (ASC-US) -Atypical Squamous Cells Suspicious for High Grade Lesion (ASC-H) -Cervical Carcinoma -Endocervical adenocarcinoma in situ (AIS) -Endometrial Cancer -High Grade Squamous Intraepithelial Lesion (HSIL) -Hyperkeratosis or Parakeratosis -Low Grade Squamous Intraepithelial Lesion (LSIL) -Reactive Changes due to Inflammation -Adenocarcinoma -Unsatisfactory for Evaluation -Negative for Intraepithelial Lesion or Malignancy P (Plan): Testing: PAP Smear (Papanicolaou Smear) Therapy/Treatment: To be determined by results of PAP smear. Education: The pap smear exam is completed during the female pelvic exam. A sample is taken from the inner and outer surface of the cervix and sent to the laboratory for microscopic exam of the cells to be screened for pre-malignant lesions and cervical cancer. When a patient has a negative pap smear result this indicates that the cervical cells were not at risk for the development of cervical cancer at the time of the test. If the pap smear results return positive the patient is at risk for cervical health issues, possibly cancer. Patient needs to be further evaluated and tested. Over the past 30 years the pap smear has helped to decrease the incidence of cervical cancer by greater then 50%. In order to continue to see the rate of cervical cancer decrease both Case Study: Cervical Cytology Screening 7 practitioners and patients must work together to ensure that pap smear testing is being completed annually, as recommended by the American College of Obstetricians and Gynecologists (ACOG), or according to the patients age, risk group, and previous study results. Follow-up: No follow-up needed at this time. The patient will be contacted with result of PAP smear and the need for additional testing, if appropriate, when results are returned to the office. Differential Diagnosis Based on the above patient’s subjective and objective assessment, differential diagnoses were determined. The patient presented for a routine gynecological exam. Patient had a history of an abnormal pap smear, revealing ASC-US. The abnormal results called for advanced interventions, including colposcopy. Therefore, differential diagnoses focused on the potential results of the PAP smear that was collected during the pelvic exam. The first differential diagnosis is a normal PAP exam, reported as “negative for intraepithelial lesion or malignancy” (Clinical, 2015, p. 3). Another result of the pap screen could reveal that the specimen was “unsatisfactory” for evaluation. This result can be due to the absence of cervical cells in the specimen or the cytologist’s inability to complete the test because the cells are inflamed or contaminated with blood. Epithelia abnormalities, including atypical squamous cell (ASC), could also be reported as a result of the PAP, which would reveal that a small degree of nuclear atypical was seen during microscopic examination. However, the severity was not ample to warrant the diagnosis of squamous intraepithelial lesion. Furthermore, ASC can be divided into two sub-categories including Atypical Squamous Cells of Undetermined Significance (ASC-US) and Atypical Squamous Cells Suspicious for High Grade Lesion (ASC-H), which were both included in the differential diagnosis. A fourth potential result/diagnosis of the pap is the presence of atypical glandular cells (AGC). AGC designates glandular atypical cells which are Case Study: Cervical Cytology Screening 8 identified in the cytology report as atypical endocervical cells, atypical endometrial cells (possible endometrial cancer), or atypical glandular cells not otherwise specified. In addition, AGC results can further identify endocervical adenocarcinoma or adenocarcinoma in situ (AIS). Low Grade Squamous Intraepithelial Lesion (LSIL) is also reported as a result of pap testing, indicating mild dysplasia consistent with HPV infections. In addition, High Grade Squamous Intraepithelial Lesions (HSIL) can be found on pap examination which specify moderate or severe dysplasia or carcinoma in situ (Cervical, 2014). Another result of the pap could reveal Hyperkeratosis or Parakeratosis which is associated with trauma or infection of the cervix (Penson, 2013). Finally, Cervical Carcinoma or Squamous Cell Carcinoma can be reported as a result of PAP testing (Cervical, 2015). Overall, all the potential results of pap testing were including the differential diagnosis and the working diagnosis will be given when the result of the patient’s pap test is returned from the laboratory. Orders Liquid based cervical cytology was utilized for pap screening during the pelvic examination. The liquid based technique, which 90% of obstetricians and gynecologist utilize, allows the practitioner to collect exfoliated cells form the transformation zone of the cervix and transfer them to a “vial of liquid preservative that is processed in the laboratory to produce a slide for interpretation” (Cervical, 2015, p. 2). Utilization of the liquid based test has decreased the number of rejected tests due to blood, discharge, inflammatory cells, and lubricant contamination because of its unique ability to filter out the debris (Cervical, 2015). In addition, “prompt suspension of the cells in the liquid eliminates the problem of air drying artifact” (Cervical, 2015, p. 2). The liquid based method also allows the practitioner to test for gonorrhea and chlamydia infections in addition to the HPV testing. Moreover, cytologists report that liquid Case Study: Cervical Cytology Screening 9 based tests are simple to interpret. But, while there are numerous advantages to using liquid based cytology collection for pap testing, as compared to the conventional method, there are also a few disadvantages. Liquid based test are more expensive to collect than the conventional test and have demonstrated decreased sensitivity specificity for diagnosing atypical cells (Cervical, 2015). Overall, the cervical cytology screening guideline states that “both liquid-based and conventional methods of cervical cytology are acceptable for screening” (Cervical, 2015, p. 8). Identify the First and Second Line Treatment The clinical practice guidelines for the management of women with abnormal cervical cancer screening tests, published by the American Society for Colposcopy and Cervical Pathology (ASCCP), identify specific treatment measures for patients with cervical cytology results of ASC-US. The guideline states that for women over twenty years of age there are three acceptable ways to initially manage patient care when pap cytology results return as ASC-US. The first approach is to repeat the cytology results at six and twelve months. If both tests are negative the patient can return to the routine screening methods, based on their history of ASCUS. But, if any form of atypical squamous cells are found on either cytology test colposcopy is recommended to provide a more detailed examination of the cervical cells. The second suitable way to manage ASC-US is to complete “reflex” human papaloma virus (HPV) testing with liquid based cytology. This approach is normally chosen for post-menopausal woman because the incidence of ASC-US and HPV in this particular population is very low (Management, 2014; National, 2014). Therefore, HPV testing “is more efficient in older women because it refers a lower proportion of these women to colposcopy” (Management, 2014, p. 6). If testing results are negative for HPV than repeat cytology is recommended in twelve months. On the other hand, if the HPV test is positive colposcopy should be performed. Consequently, the third acceptable Case Study: Cervical Cytology Screening 10 method of managing patients with ASC-US is colposcopy, the exam that is completed if either of the first two option tests return positive. For example, if the repeat cytology is positive or the HPV DNA testing is positive, colposcopy is recommended. If colposcopy results return positive for cervical intraepithelial neoplasia (CIN) management must shift to the specific CIN treatment recommendations provided in the ASCCP guideline. But, if colposcopy results return negative for CIN and the patient’s HPV status is unknown a repeat cytology should be completed in twelve months. On the other hand, if the patient had a history of high risk types of HPV and had previously tested positive for HPV the practitioner could repeat cytology in six and twelve months or complete HPV DNA testing in twelve months. If the repeat cytology either at six or twelve months reveals abnormal cells for HPV repeat colposcopy is suggested. But if both cytology exams return negative, or when you have two negative tests in a row, the patient can return to a routine cytology screening schedule. Furthermore, if the practitioner decides to wait to perform HPV DNA testing at twelve months and it returns negative then the patient can return to routine screening, with history of ASC-US and HPV (Management, 2014; National, 2014). Overall, the practitioner selects the appropriate evidenced based management plan out of the three presented in the ASCCP guideline to create the best care plan for the patient based on their history and physical. The clinical practice guidelines for the management of women with abnormal cervical cancer screening tests was created in 2006 and last reviewed in 2009. The guideline was developed and funded by the Medical Specialty Society of the American Society of Colposcopy and Cervical Pathology. Specific details on guideline committee formation, meetings, and composition methods for the guideline were not disclosed. In addition, financial disclosures and Case Study: Cervical Cytology Screening 11 conflicts of interest were not stated in the guideline. On the other hand, authors of the guideline were recognized (National, 2014). Primary authors included: Thomas C. Wright Jr, MD, Department of Pathology, College of Physicians and Surgeons of Columbia University, New York, NY; L. Stewart Massad, MD Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, MO; Charles H. Dunton, MD, Department of Obstetrics and Gynecology, Lankenau Hospital, Wynnewood, PA; Mark Spitzer, MD, Department of Obstetrics and Gynecology, Brookdale University Hospital and Medical Center, Brooklyn, NY; Edward J. Wilkinson, MD, Department of Pathology, University of Florida College of Medicine, Gainesville, FL; Diane Solomon, MD, National Institutes of Health and National Cancer Institute, Bethesda, MD (National, 2009, p. 14). Prior to publication the guideline was reviewed by numerous professional practice organizations including the American Society of Family Physicians, American Cancer Society, American Society for Clinical Pathology, American Society for Colposcopy and Cervical Pathology, Center for Disease Control and Prevention, and numerous other International Societies, among others (National, 2014). Overall, the guideline was authored by many experts in the fields of women’s health and pathology and is supported by numerous professional organizations, which supports its content and application to medical practice. In conclusion, it is imperative that practitioners follow the clinical practice guidelines for the management of women with abnormal cervical cancer screening presented by ASCCP according to the patient’s individual presentation to ensure the best possible patient outcomes. Epidemiology Case Study: Cervical Cytology Screening 12 The incidence of cervical cancer has significantly decreased over the past decade due to increased cervical cancer screening initiatives with PAP smear testing. In 2007 the incidence of cervical cancer in the United States (U.S.) among women was 7.8 per 100,000 as compared to 6.4 per 100,000 in Maryland. More specifically, in Caroline County, MD where the patient in the presented SOAP note resides there were no reported cases of cervical cancer. However, in 2007 both the U.S. and Maryland cervical cancer mortality rate was 2.4 per 100,000 women (Poppell, King, Groves, Dwyer, Sage, & Hussein, 2015). Therefore, these statistics indicate that women in Maryland who are diagnosed with cervical caner are either not being treat being treated appropriately or are being diagnosed to late in the disease process to prevent mortality. “In 2007, 38.1% of all cervical cancer cases in Maryland were diagnosed at the localized stage, 34.5 were diagnosed at the regional stage, and 16% were found at the distant stage” (Poppell, et al., 2015, p. 119). One of the Healthy People 2010 goals for cervical cancer screening across the U.S. is to have 90% of women age 18 years report PAP testing within the past three years. In 2002 Maryland hit the 92 percentiles for this particular Healthy People 2010 goal, but has decreased in percentage every year since landing at 84% in 2008 (Poppell, et al., 2015). It is imperative that Maryland examine and plan to break down the current barriers that are impinging them from providing the preventative measures needed, as identified in the current practice guidelines, to diagnose and treat, thus decrease the mortality rate of cervical cancer. Preventative Treatment There are numerous preventative treatment measures that can be taken against cervical cancer that practitioners should share with their female patients of all ages. Adolescent patients should be educated that certain activities including abstinence from smoking, second hand smoke, and sexual activity will minimize their risk of contracting a HPV infection which is Case Study: Cervical Cytology Screening 13 directly related to cervical cancer. For patients ages 9-26 year’s vaccination against HPV, the etiologic agent of cervical cancer, is recommended. When patients are sexually active, preventative measures include the utilization of barrier protection and/or spermicidal gel during sexual intercourse, is recommended. In addition, women should be informed that high parity is also associated with an increased risk of cervical cancer (Poppell, et al., 2015). Finally, “screening of appropriate women via regular gynecologic examinations and cytology test (pap test, either conventional or liquid-based cytology), with treatment of precancerous abnormalities, reduces the mortality from cervical cancer” (Poppell, et al., 2015, p. 121). Pap testing should begin at age 21 if the patient is not sexually active. When adolescents are sexually active prior to the age of 21 pap screening should be completed three years after onset of sexual activity or at age 21, which ever comes first (Cervical, 2009; Poppell, et al., 2015). Between the ages of 21 and 20 pap cervical cytology is recommended every 2 years, if all testing results are normal (Cervical, 2015). “Women aged 30 years and older who have had three consecutive negative cervical cytology screening test results and who have no history of CIN2 or CIN3, are not HIV infected, are not immunocompromised, and were not exposed to diethylstilbestrol in utero my extend the interval between examination to every 3 years” (Cervical, 2015, p. 8). Women with a history of abnormal pap or an unknown cervical screening history are at risk for development of cervical caner for 20 years and should have annual cytology testing completed (Cervical, 2015). Cervical cancer screening can be discontinued for patients between 65 and 70 years of age who have had “three or more negative cytology test results in a row and no abnormal test results in the past 10 years” (Cervical, 2015, p. 8). Cytology testing can be discontinued for patients who have undergone hysterectomy for benign diagnoses. On the other hand, pap screening of the vaginal cuff should be continued for women who have had hysterectomies secondary to Case Study: Cervical Cytology Screening 14 abnormal cells and/or cancer (Cervical, 2015). Overall, it is imperative that practitioners follow the latest evidenced based guidelines for cervical cytology screening in order to diagnose and treat abnormal cervical cells, thus decreasing the incidence and mortality of women with cervical cancer both locally and globally. Prescribed Management Comparison The standard of care management approach for abnormal cervical cytology screening, focusing on ASC-US, differed slightly from the prescribed management plan presented in the SOAP note. In June 2016, the patient had a pap completed revealing ASC-US cytology results. A referral was then made to a GYN for the abnormal results. The GYN decided to complete a colposcopy during August 2010, which is one of the three acceptable first line management tests for patients with ASC-US. The results of the colposcopy were negative for CIN and since the patient’s HPV status was unknown repeat cytology was ordered. The difference in the prescribed management plan arose when the GYN prescribed repeat cytology in three months and not in one year as proposed in the clinical practice guideline. But, due to numerous circumstances the patient did not have the repeat cytology completed until one year later, as the guideline recommends. In the end, the patient received proper management for her diagnosis according to the guidelines. An evidenced based plan of care will be created when the cytology results from her current exam return. Case Study: Cervical Cytology Screening 15 References Arcangelo, V.P. & Peterson, A.M. (2015). Pharmacotherapeutics for advanced practice: A practical approach (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Bickley, L. S. (2009). Bates’ pocket guide to physical examination and history taking (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Clinical Management Guidelines for Obstetrician-Gynecologists. (2015, December). Cervical cytology screening. The American College of Obstetricians and Gynecologists Women’s Health Care Physicians. Washington, DC. Clinical Management Guidelines for Obstetrician-Gynecologists. (2014, December). Management of abnormal cervical cytology and histology. The American College of Obstetricians and Gynecologists Women’s Health Care Physicians. Washington, DC. Domino, F. J. (Eds.). (2015). The 5-minute clinical consult. Philadelphia: Lippincott Williams & Wilkins. National Guideline Clearinghouse. (2014). 2006 consensus guideline for the management of women with abnormal cervical cancer screening tests. U.S. Department of Health and Human Services. Retrieved July 4, 2017, from http://www.guideline.gov/content.aspx? Id=14698&search=american+society+for+colposcopy+and+cervical+pathology Penson, T. T. (2015, June 21). Abnormal pap smear. Epocrates, Inc. Retrieved July 4, 2017 from http://online.epocrates.com/noFrame/showPage.do?method =disease&MonographId=1123&ActiveSectionId=22 Poppell, C. F., King, M., Groves, C., Dwyer, D. M., Sage, K., & Hussein, C. A. (2015, July. Cancer report 2017 revised. Maryland Department of Health and Mental Hygiene. Baltimore, MD. SOAP NOTE TEMPLATE Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with vaginal discharge, you would examine the General appearance, Heart and Lungs, abdomen and pelvis for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice. The only section that will not be included in a real chart is differential diagnosis. The term “Rule Out…” cannot be used as a diagnosis. Subjective Data (20 pts.) Chief Complaint (CC): History of Present Illness (HPI): Last Menstrual Period (LMP) Allergies: Past Medical History: Family History: Surgery History: Obstetrical/GYN History: Social History (alcohol, drug, or tobacco use): Current medications: Review of Systems (Remember to inquire about body systems relevant to the chief complaint and HPI) Objective Data (25 pts.) Please remember to include an assessment of all relevant systems based on the CC and HPI. Vital Signs/ Height/Weight: General Appearance: Assessment (20 pts.) A: Differential Diagnosis Please rule out all differential diagnosis with subjective and objective data and/or lab-work. Provide references. 1. 2. 3. B: Medical Diagnosis Rule in diagnosis with subjective and objective data and lab-work. Please explain how you arrived at the diagnosis. Provide references. 1. PLAN (25 pts.) A: Orders 1. 2. 3. 4. 5. 6. Prescriptions with dosage, route, duration, amount prescribed, and if refills are provided Diagnostic testing needed Problem oriented education Interpersonal/Social support/communication Age appropriate Health Promotion/Maintenance/Screening Needs Referrals and follow up with rationales Cultural Diversity: What cultural considerations would you suggest for this patient? Patient/Family Education: If patient is currently on any medications, please address if you want them to discontinue or continue. You always want this to be clear at the end of the visit. B: Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit ---F/U in 2 weeks; Plan to check annual labs on RTC (return to clinic) with rationales APA Format (10 pts.) Include a title page and references with all of your papers. There should be at least four references from textbooks, journal articles, CDC or NIH that are not older than 5 years. Please do not use Wikipedia, WebMD, dictionaries, or any websites that are not evidence based.
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SOAP NOTES:
SUBJECTIVE DATA:
Chief Complaint: Vaginal Bleeding, 16-weeks pregnant
History of Present Illness: 21-year-old Caucasian female that presents to the clinic with a chief
complaint of vaginal bleeding, along with mild cramping that started this morning. She is getting
prenatal care as she has had a prior visit, where she also had an ultrasound. She states this is her
first pregnancy.
Medications: Prenatal Vitamin 1 tab by mouth daily
Allergies: No known drug allergies or food allergies.
Past Medical History: Asthma, Scoliosis.
Past Surgical History: No prior surgeries.
Personal/Social History: She denies any smoking in her past or currently. She also denies any
illicit drug use. States she is a social alcohol user prior to her pregnancy. She runs about a mile
every other days as stated. She also states that she
Immunizations: Tetanus Immunization was last taken 2010. She has never taken an Influenza
immunization.
Family History: Her father has Hypertension and her mother has no medical history. There are
three sisters ages 31, 25, and 18. No brothers.
OB/GYN: Gravida 1, Full term 0, Premature 0, abortion 0, living 0. Her last menstrual period
was on 01/24/2015. States her pregnancy was verified here at the clinic last visit. Pregnancy was
dated at 16 weeks and 0 days today.
Review of Systems:

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General: Generally in good health. No medical conditions. Stays in shape and denies an...


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