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MN552 PPT Complete U1 10 (7)

MN552 PPT Complete U1 10 (7)

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MN552: ADVANCED HEALTH ASSESSMENT AND DIAGNOSTIC REASONING JERRICA SHERIDAN DNP, FNP-C UNIT 1 SEMINAR OBTAINING HEALTH HISTORY SOAP NOTES  Subjective  Chief complaint  History  Review of Systems  Objective  Physical Exam (rest of PPT)  Diagnostics  Assessment  Diagnosis  Plan  Orders  Rationale CHIEF COMPLAINT (SUBJECTIVE)  This is why the patient is seeking care  Usually just a few words or a brief sentence  Ex) Abdominal Pain  Ex) Well woman exam, PAP smear  Ex) Hypertension  Ex) Urinary burning and frequency HEALTH HISTORY (SUBJECTIVE)  Includes the following:  Subjective data of current visit (HPI)  Ex) Patient here today for evaluation of abdominal pain that has been occurring for 3 days. She reports it is in the left lower abdomen and is sharp in nature. Pain is intermittent and nothing seems to make better or worse. Rates pain 4/10. Has not been taking any medication to help. Normal BM and no urinary symptoms. No past history of abdominal surgery.  Ex) Patient here today for well woman visit including PAP smear and STD testing. G2P1, miscarriage at 10 weeks that was 3 years ago. Menarche age 13, cycles every 29 days for 4-5 days of medium flow. Mild dysmenorrhea that responds to Ibuprofen. No vaginal discharge or issues today. Same male sexual partner for the last 5 years. No exposure to STDs that she is aware of. Last PAP normal 3 years ago.  Past Medical History  Past ...
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