Diagnosis, and treatment and management plan
Think about the details of the patient’s background, medical history, physical eval, 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 eval 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 assessment
· Labs, and other diagnostics
· Differential diagnoses
· Management plan, including diagnosis, treatment, patient education, and follow-up care
· Provide evidence-based guidelines to support treatment plan.