Episodic Visit: Gynecology Focused Note
Subjective: What details did the patient provide regarding her personal and medical history?
The patient is for annual Gyn visit. 35-year-old present for an exam, breast mammogram is scheduled. Assignment
Patient missed annual visit last year and planning catchup this year . Liva alone not married but a boyfriend and No birth control used by her , he is the person to provide protection. She is preparing to have kids in the next year. History of UTI without signs reported or assessed.
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, as well as a rationale for this treatment and management plan.
Her meds are aspirin 81mg daily, allergery meds as needed, Tums as needed with her meals by mouth, Melatonin 3mg as needed by mouth at night
Reflection notes: What would you do differently in a similar patient evaluation?
I would offer vitamins and during the COVID more on the immune support to keep her healthy. Currently no need for help or a concern with preparing for pregnancy .
Patient histories are a building block of the diagnosis and treatment. By effectively interviewing patients in their care, advanced practice nurses can piece together facts to construct a relevant history that can lead to assessment and treatment.
For this Focused Note Assignment, you will select a patient with gynecologic conditions from your clinical experience and construct a patient history, assess and diagnose the patient’s health condition(s), and justify the best treatment option(s) for the patient.