Management plan, including diagnosis, treatment, patient education, and follow-up care

• 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.
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.
Reflection
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?