- Reflect on your practicum experience and select a female patient whom you have examined with the support and guidance of your Preceptor.
- Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, and treatment and management plan, and education strategies and follow-up care.
- What additional considerations might you think about if your patient was pregnant or just delivered?
- Use the “Guidelines for Comprehensive History and Physical SOAP Note” document found in this week’s Learning Resources to guide you as you complete this Assignment.
Write an 8- to 10-page Comprehensive Well-Woman Exam that addresses the following:
- Age, race and ethnicity, and partner status of the patient
- Current health status, including chief concern or complaint of the patient
- Contraception method (if any)
- Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)
- Review of systems
- Physical exam
- Labs, tests, and other diagnostics
- Differential diagnoses
- Management plan, including diagnosis, treatment, patient education, and follow-up care
- Provide evidence-based guidelines to support treatment plan. Note: Use your Learning Resources and evidence from scholarly sources from your personal search to support your treatment plan of care.
Reflect on some additional factors for your patient:
- What are the implications if your patient was pregnant or just delivered?
- What are implications if you have observed or know of some domestic violence? Would this change your plan of care? If so, how?