[GET] Well Woman Exam Soap Note
Diagnosis can be made based on the result of three out of the four tests according to WH Also, laboratory test for wet mount test; whiff test; vaginal pH test are all positive, and when these tests are positive with the vaginal discharge that is synonymous with bacterial vaginosis, the diagnosis of bacterial vaginosis is established. Vaginal Candidiasis: Commonly known as yeast infection. The infection is caused by fungus candida, which causes extreme itching, swelling, and irritation. Symptoms include rash, vaginal discharge that is usually thick, white, and odorless; itching, burning, pain during sex, soreness, and burning.
Files related to Well Woman Exam Soap Note
THE SOAP NOTE!!!
Laboratory test or check is needed to diagnose the infection. Trichomoniasis is ruled out as the possible differential diagnosis because the patient discharge is not frosty, yellow-green. PLAN: Diagnostic plan: Oligonucleotide probes test will be ordered and send out to outside diagnostic lab company. Results: positive. Treatment and Management: Bacterial vaginosis resolved spontaneously for most women, but the patient has been having the symptoms for one week.
Tina jones neurological assessment soap note
I will use an antibiotic therapy. Antibiotics Therapy: Metronidazole Flagyl , mg orally twice daily for seven days. Alternative Therapy I will recommend probiotics, such as Lactobacillus acidophilus, which will help eliminate high levels of bad bacteria and replace them with good bacteria. The rationale is that acidophilus is a known good bacteria. Also, I will recommend apple cider vinegar; the rationale is that bacterial vaginosis is caused be change in vaginal pH. Nonpharmacological Treatment: Yogurt will be recommended to the patient, and patient advised to eat two cups of plain yogurt daily. Rationale is to restore normal pH balance in the vagina inhibiting the growth of bad bacteria. Moreover, tea tree oil will be recommended to the patient, and patient will be instructed to add few drops of tea tree oil in warm water, stir the water and use the water to rinse vaginal daily for three to 4 weeks Machado et al. The rationale is to kill the bacteria that cause bacterial vaginosis as well as eliminate the foul fishy odor associated with bacterial vaginosis because tea tree oil has both natural antibacterial and antifungal compounds.
The Ultimate Guide to SOAP Notes for Veterinarians and Healthcare Professionals
Furthermore, patient will instructed to eat raw or cooked garlic daily because the garlic natural antibiotic properties. The rationale is to keep the eliminate bad bacterial Machado et al. Health Promotion: Patient will be educated to wipe from front to back instead of back to front to void contaminating the vagina with bacterial from the rectum. Also, patient will be educated to keep her vulva clean and dry. In addition, patient will be educated to refrain from using agents that are irritating in her vagina, such as strong soaps, feminine hygiene sprays, or douching. Furthermore, patient will be educated to abstain from tight jeans, panty hose with no cotton crotch, or clothing that trap moisture.
How to Write a SOAP Note With Obstetric Examples
Have only single sex partner and use condom Public Health, Reflection Note and Follow-Up What I will do differently on a similar patient evaluation is that I will check the patient hemoglobin A1C to rule out diabetic origin of the condition. I would send the patient home to try the recommended home remedies for few days and come back for antibiotic treatment since bacterial vaginosis can be resolved without treatment to prevent antibiotic resistance. Patient will be schedule to follow-up in 14 days to repeat the diagnostic test to make sure that the infection is cleared, and if the infection is not cleared, I will repeat antibiotic treatment. I agree with my preceptor diagnosis based on the available positive test results and clinical guidelines.
Male Gu Soap Note
Homework solution attached Purchase this answer to view it This homework is solved by this writer. You can always ask and chat with this writer about your homework needs.
Samples Nursing Papers
Not addressed. What would you do differently? You addressed this. What additional data would you have gathered? What additional elements of the exam would you have done? Not addressed Do you agree with your preceptor? She believes she has PMS and wants to know if there is a medication to control it. Unfortunately, there is a stigma for females regarding the seriousness of physiologic changes that occur in regards to menstruation for which many studies have been conducted. As a provider in this scenario, I feel the most important next step in managing her care is to recognize that what she is experiencing are indeed real symptoms for a real condition for women. This establishes trust and rapport with patients and validates their feelings. The last thing a provider should do is dismiss the feelings and concerns of a patient.
Np soap notes
The provider should inquire about the specific symptoms the patient is experiencing and the frequency of occurrence to accurately diagnose. The patient should be encouraged to keep a journal of her symptoms and dates to help establish a timeline to aide in diagnosis. It is the severity of the symptoms that differentiate the two disorders. PMS is defined as a cluster of mild to moderate physical and psychological symptoms and PMDD encompass cognitive, behavioral, emotional, and negative symptomatic changes that severely impair daily functioning Schuiling 7 likis, The American College of Obstetricians and Gynecologist ACOG state that in order to diagnose PMS or PMDD a patient must accurately report and record their symptoms previously mentioned for at least two to three months and the symptoms must be present in the 5 days before her period for at least three menstrual cycles in a row, end within 4 days after her period starts, and interfere with some of her normal activities.
Musculoskeletal Soap Note
Contraception as Treatment Once an official diagnosis of either PMS or PMDD is made, the provider and patient should communicate common goals and discuss a collaborative approach for management. In terms of choosing the correct pharmacological intervention, the provider needs to determine if the patient is experiencing more physical disturbances of psychological issues. It is vital that providers discuss the background of a situation and develop a common goal for management before determining the best treatment. There are many people that are opposed to taking daily medications and prefer lifestyle modifications and holistic approach and if that is not something you are able to accommodate as a provider, than a referral should be made. Providers should always listen and respect the wishes of patients and involve them in their own treatment plans and providing appropriate education is key.
Back to Basics: The Well-Woman Visit
Tharpe, Farley, and Jordan state that treatment should be aimed at finding relief measures that are acceptable for the individual and must support the patient in the context of their life. American College of Obstetricians and Gynecologist. Premenstrual syndrome: FAQ. Premenstrual syndrome and premenstrual dysphoric disorder. American Family Physician, 1;94 3 , The role of estrogens in control of energy balance and glucose homeostasis.
Fatigue soap note
Endocrine Soceity 34 3 , Premenstrual syndrome: A mini review. Maturitas, 82 4 , Choosing a combined oral contraceptive pill. Australian Prescriber, 38 1 ,
Np soap note
HPI: The patient presented with painful urination, vaginal discharge and coitus pain. She also noted an increase in vaginal bleeding, Pap tests taken have been abnormal and pelvic area has also been experiencing pain. This has been going on for two weeks, for which she has been using OTC Ibuprofen. Hospitalizations: None. Social History: She is an occasional smoker and is a social drinker. She denies use of illicit drugs. She tries to stay active by doing Zumba dance during free times. She works as a Lyricist for a music company.
well woman exam soap note example
ROS: Constitutional: The patient appears unwell and is worried that the symptoms are gradually increasing and it has even started to affect his day to day life because of the pain. She denies incidences of fever, diarrhea, nausea and weight gain or loss. Hearing capability seems normal. Uses reading glasses. Cardiovascular: Normal heart rate and denies any murmurs, gallops and clicks. Respiratory: The chest rises and falls rhythmically with the patient not complaining of wheezing, and coughing.
Top Exams 2021
Gastrointestinal: Denies diarrhea, abnormal bowel movements and pain in the abdomen. Genitourinary: Complains of pain while urinating, painful coitus, pain in the pelvic area, vaginal discharge and abnormal bleeding. Patient denies hematuria, urgency and frequency in urination. Musculoskeletal: The patient denies any pain in the muscles, back pain or pain in the joints.
Free Soap Notes Templates for Busy Healthcare Professionals
Neurologic: The patient has no deformities with the balance and is sensitive to the stimuli. Psychiatric: Denies insomnia, nightmares, suicidal thoughts and abnormal headache. She looks distressed. Head: No deformities or poor hair growth observed. Eyes: Sclera white, normal light sensitivity and no abnormal discharge, no redness Ears: Bilaterally intact, TM intact, no discharge Nose: Pink and Moist mucosa, no sneezing or excessive discharge or congestion, no polyps Throat: No Inflammation, swelling or dislocation. Respiratory: Chest clear, no wheezing or rales Gastrointestinal: No diarrhea or constipation; generalized tenderness; bowel sounds present in all 4 quadrants. Genitourinary: Painful urination, painful coitus, pain in the pelvic area, vaginal discharge and abnormal bleeding, no hematuria, urgency and frequency in urination. Musculoskeletal: Normal gait, no muscular tenderness or swelling Neurologic: The patient has normal gait, responds effectively to all temperature extremes.
Well Woman Exam Soap Note
Psychiatric: No insomnia, nightmares, suicidal thoughts. Labs: Pap smear, endometrial biopsy, Curettage and dilation, transvaginal ultrasound and Computed tomography. During early onset of the condition, there will be excessive vaginal bleeding that does not have a relationship with menstrual periods. The Pap smear showed abnormal results of glandular cells that are abnormal.
THE SOAP NOTE!!! – Nurse Practitioner Goals
All the other tests were positive for endometrial cancer. Endometrial Hyperplasia: Common presentation is abnormal uterine bleeding. In premenopausal women, the symptoms include irregular heavy menstruation or amenorrhea in some cases. Endometrial biopsy differentiates endometrial hyperplasia from cancer. However there in Endometriosis: Symptoms include pain, dyspareunia and painful defecation. It is common in young premenopausal women. Physical examination reveals tenderness and nodularity.
Obgyn Soap Note Example
Pelvic ultrasound can be done to confirm endometrioma Endometrial Cancer, Additionally, some of the healthy tissues that surround the tumor will be removed since they could be containing some cancer cells. Simple Hysterectomy will be ideal for the patient due to the extent of the spread of the cells Eifel, In this case, the cervix and uterus will be removed since the cancer cells have not spread so much to the other parts of the reproductive system. The patient will have to keep visiting the health facility after the procedure for routine maintenance and test to ascertain that the tumor does not regenerate.
Dermatology SOAP Note Medical Transcription Sample Reports
Reflection notes: In this case, the diagnosis itself is a big shock to the patient. Also, the pain suffered by TS is limiting her from his daily activities. Ignoring these could attribute to mood disorders or depression. She should be introduced to support groups with people going through the same diagnosis. This will also help her overcome the mental and physical pain caused by the disease. References Eifel, P. Treatment of Endometrial Cancer. Pelvic Cancer Surgery, Recurrent Endometrial Cancer.
Well Woman Encounter HPI - The SOAPnote Project
Current Concepts in Endometrial Cancer, Shafer, A. Endometrial Hyperplasia and Endometrial Cancer. Gynecological Cancer Management, We have qualified writers to help you. Order now for an Amazing Discount! NB: We do not resell papers. Upon ordering, we do an original paper exclusively for you.
Adult well-care visits, screenings, and immunizations
Please share: People who work in the human medical field, as well as veterinary science field, find themselves taking SOAP notes quite regularly. Well, it is a way of documenting the interactions with a client, as well as their progress. It can be a tedious and confusing task, yet it is absolutely necessary. A SOAP note can be considered to be a progress note containing specific information in a specific kind of format. This is done to help gather up all the important and essential information from a session that will be useful. Also, it shows you care about the needs of clients. SOAP notes can be taken a few ways. The traditional pen-and-paper method has been the most longstanding way of keeping records, although it is becoming increasingly popular to type up and dictate records as well. These notes help provide consistency internally while providing relevant information and specific details.
Adult Well-Care Visits, Screenings, and Immunizations | Kaiser Permanente Washington
They help keep things organized when it comes to a client, be they a human or animal. Well, it follows the SOAP acronym and goes like this: Subjective This is the first portion of an interaction with a client or patient. It is where they, or someone on their behalf, explains what the chief complaint is. There may be a few issues, but only one is the primary complaint. Asking the right questions leads to informative answers. Objective This portion should only include tangible information. This means including lab data, imaging results, diagnostic data, findings from a physical exam, and vital signs. Assessment This section of the SOAP notes is where you combine what you know, given the information in the subjective and objective portions.
sample well woman soap note
The veterinarian or healthcare professional will identify the main problem, as well as any contributing factors. Additionally, they will analyze any interaction between the issues that exist, along with changes that may be present. They will then diagnose the problem, form an explanation, and discuss it. This is where a healthcare professional or veterinarian will develop a plan to follow. This may include more tests, medications, dietary changes, or other helpful modalities.
- (Medical Transcription Sample Report)
He has had two melanomas in the past; one with a Clark level IV 4. There were five mitoses per square millimeter with no ulceration. Of note, for the second melanoma, there was a question of epidermotropic metastasis; however, there was an in situ component to this suggesting a primary lesion but could not completely rule out epidermotropic metastasis on the pathology report.
Encounter Forms
This was re-excised with a negative sentinel lymph node biopsy. He currently notes that he is doing well with no new or changing moles. He does point to a wart on his third finger of his left hand that he has had for quite some time. He also has one on the right finger web between the first and second digit as well. Exam included the scalp, face, eyelids and conjunctivae, lips, neck, chest, abdomen, back, buttocks, right and left upper and lower extremity. Wart : On his third finger on his left hand, he had a mm hyperkeratotic papule and this was frozen with liquid nitrogen with three brief freeze-thaw cycles. On the next visit, we will freeze it a bit harder if it appears to persist and he did not get too much of an inflammatory response; and also, on his right finger web, he had a 3 mm papule that was frozen with liquid nitrogen as well. History of melanoma x2: He had on his left forearm and left wrist two well-healed scar sites with no evidence of pigmentation or nodularity in or around the scar sites; as usual amelanotic.
Free Soap Notes Templates for Busy Healthcare Professionals
He will watch for pink lesions that are persistent, and he will continue self-skin checks. Nevi: He had relatively few brown macules and papules scattered on torso and extremities but nothing concerning for malignancy. We will see him back in one month to treat his warts if it is still present and in three months for his next skin check. He restarted clofazimine 50 mg daily for neuritis and he is still taking that. He is also on prednisone 5 mg daily for neuritis. He had a gangrenous ulcer of the left foot with amputation of the left toes and forefoot in YYYY.
No comments:
Post a Comment