Gynecologic Health

Diagnostics and Primary Diagnosis

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?

A diagnosis based significantly on laboratory reports or test results, rather than the physical examination of the patient. … Principal diagnosis. The single medical diagnosis that is most relevant to the patient’s chief complaint or need for treatment. Many patients have additional diagnoses

Diagnostic Tests Overview

Allergy testing.
Blood pressure measurement.
Blood tests.
Bone, joint and muscle tests.
Brain and nerve tests.
Biopsy (surgical removal of a tissue sample for microscopic evaluation; e.g., breast biopsy, prostate biopsy)
Cancer tests.
Digestive system tests (e.g., endoscopic procedures such as colonoscopy and barium enema)

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)