see attached
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Name:
Jessica Dale |
Pt. Encounter Number: 2 |
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Date: January 30, 2023 |
Age: 18 |
Sex: Female |
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SUBJECTIVE |
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CC: “I want to get on the pill before I go to college.”
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HPI: 18 yo Caucasian female presents to office seeking contraception. She is preparing to go away to college and would like to prevent pregnancy but is concerned about weight gain. She has friends who use contraception in a way that they do not have menses and she is interested in this as well, but she is concerned about the safety of this option. States she had unprotected vaginal sex with a male 1 year ago. Not currently sexually active or in a relationship. Onset of menses age 13. Reports regular menses once monthly lasting 6-7 days with normal flow. She reports lower back pain and cramping beginning the day prior to menses. She has treated these symptoms with Midol and heating pad with relief.
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Medications:
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Allergies:
Medication Intolerances: |
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Past Medical History:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries:
Preventative: TDAP 6 years ago |
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Family History Mother: asthma Father: basal cell carcinoma removal, HTN
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Social History She has completed high school and plans to transfer to University of Florida in a few weeks and will live in the dorms. Currently lives at home with her family and feels safe there. Denies use of alcohol or drugs although she admits that she has not ruled out the possibility of drinking once at college. Tried vaping once and felt sick, no further tobacco use. She has been sexually active in the past but is not currently. Not currently in a relationship.
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ROS Student to ask each of these questions to the patient: “Have you had any…..” |
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General Denies recent weight change but has concerns about weight gain with oral contraception use. Denies fever, chills, night sweats or fatigue.
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Cardiovascular Denies.
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Skin Denies any skin issues but reports recently beginning a new skin care routine.
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Respiratory Denies.
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Eyes Denies.
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Gastrointestinal Denies. |
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Ears Denies.
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Genitourinary/Gynecological Denies urinary issues. Has not had PAP or pelvic exam. Onset of menses age 13. 6-7 day cycle, normal flow. Back pain and cramping one day prior to onset. Not currently sexually active but has been past. Has used condoms. Has not tested for STI’s.
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Nose/Mouth/Throat Denies.
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Musculoskeletal Denies. |
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Breast Denies |
Neurological Denies. |
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Heme/Lymph/Endo Denies. |
Psychiatric Denies. |
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OBJECTIVE |
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Weight 125lbs BMI 20.2 |
Temp 97.9 |
BP 112/62 |
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Height 5’6” |
Pulse 69 regular |
Resp 16 pattern normal |
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General Appearance Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. |
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Skin Nose ring left nares. Acne noted along jaw line. |
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HEENT Head is normocephalic, atraumatic. PERRLA. EOMs intact. Ears: Canals patent. Nose: Nasal mucosa pink. Neck: Supple. Full ROM; no lymphadenopathy. No thyromegaly or nodules. Oral mucosa, pink and moist. Teeth are in good repair. |
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Cardiovascular S1, S2 with regular rate and rhythm. Capillary refills two seconds. Pulses 3+ throughout. No edema. |
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Respiratory Symmetric chest wall. Respirations regular and easy; lungs with wheezes bilaterally. Nonproductive cough noted. |
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Gastrointestinal Abdomen soft, nontender. BS active in all the four quadrants. No hepatosplenomegaly. |
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Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin. |
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Genitourinary Bladder is nondistended; no CVA tenderness. Speculum exam performed. No cervical lesions. No visible discharge or blood in vaginal vault. No vulvar lesions noted. Uterus anteverted, mobile and nontender. Adnexa palpable bilaterally, nontender. Rectal exam reveals no mass, good sphincter tone. |
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Musculoskeletal Extremities atraumatic, no tenderness or deformity. Full ROM in all four extremities. |
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Neurological Speech clear. Sensation intact. Judgement appropriate. |
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Psychiatric Alert and oriented. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. |
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Lab Tests ***Beta quantitative HCG < 5mIL/ml Urinalysis negative Urine pregnancy test negative KOH negative NAAT negative |
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Assessment |
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· **Encounter for contraceptive management, High risk sexual behavior, Hormonal Acne · Include at least three differential diagnoses · Provide rationale for each differential diagnosis · Final diagnosis ****Encounter for contraceptive agent, hormonal acne · Pathophysiology of primary and rationale for choosing as final |
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Plan |
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· ******Educate on safe sex practices including condom use, follow up one year, start on continuous monophasic combined hormonal contraceptive pill, start on tetracycline antibiotic for hormonal acne. · Medications · Non-pharmacological recommendations · Diagnostic tests · Patient education · Culture considerations · Health promotion · Referrals · Follow up |
I completed the note with the portions provided in the VR lab.
**** next to info provided in lab, need Assessment and Plan portions completed please.
Rubric is the same as the last assignment.
SOAP Note Write Up for VR Patient Jessica Dale
This assignment will demonstrate your ability to provide age-appropriate anticipatory guidance while recognizing the need to refer patients that are outside of the scope of practice of the family nurse practitioner. This will be demonstrated by completing a SOAP note based on a patient Jessica Dale seen in Unit 4 in the VR platform.
Write-ups
The SOAP note serves several purposes:
1. It is an important reference document that provides concise information about a patient’s history and exam findings at the time of patient visit.
2. It outlines a plan for addressing the issues which prompted the office visit. This information should be presented logically and prominently features all of the data that’s immediately relevant to the patient’s condition.
3. It is a means of communicating information to all providers involved in the care of a particular patient.
4. It allows the NP student to demonstrate their ability to accumulate historical and examination-based information, use their medical knowledge, and derive a logical plan of care.
Knowing what to include and what to leave out will largely depend on experience and your understanding of illness and pathophysiology. If, for example, you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary risk factors when writing the history. As you gain experience, your write-ups will become increasingly focused. You can accelerate the process by actively seeking feedback about all the SOAP notes you create and reading those written by more experienced practitioners.
The core aspects of the SOAP note are described in detail below.
For ease of learning, a
SOAP note template
has been provided. This assignment requires proper citation and referencing because this is an academic paper.
S: Subjective information. Everything the patient tells you. This includes several areas, including the chief complaint (CC), the history of present illness (HPI), medical history, surgical history, family history, social history, medications, allergies, and other information gathered from the patient. A commonly used mnemonic to explore the core elements of the history of present illness (HPI) is OLD CARTS, which includes: Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatments, and Severity.
O: Objective is what you see, hear, feel or smell. Your physical exam, including vital signs.
A: Assessment/your differentials
P: Plan of care including health promotion and disease prevention for the patient related to their age and gender.
If there are any questions, please contact your instructor.
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