Posted: June 14th, 2023

Episodic Visit: Gynecology Focused Note

Nursing
Title: Episodic Visit: Gynecology Focused Note
Number of sources: 3
Paper instructions:
Please see the information guide for soap paper.

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

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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.

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Subjective

Patient is a 35-year-old female who is presenting for her annual gynecological exam.
She is single and does not have any children.
She is sexually active and uses condoms for birth control.
She has a history of urinary tract infections (UTIs).
She is currently taking aspirin 81 mg daily, allergy medication as needed, Tums as needed with meals, and melatonin 3 mg as needed at night.
She is otherwise healthy and has no other medical problems.
Objective

Vital signs: BP 120/80, HR 80, RR 16, SpO2 98% on room air
General: Well-developed, well-nourished female in no acute distress
HEENT: Pupils equal, round, and reactive to light; Sclerae anicteric; Oropharynx moist and pink
Neck: No jugular venous distension; No lymphadenopathy
Lungs: Clear to auscultation bilaterally
Heart: Regular rate and rhythm; No murmurs, rubs, or gallops
Abdomen: Soft, non-tender, non-distended; No hepatosplenomegaly; No masses
GU: External genitalia without lesions; Vaginal discharge clear and non-odorous; Cervix smooth, pink, and non-erythematous; Uterus anteverted, non-tender, and mobile; Ovaries not palpable
Assessment

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The patient is a healthy 35-year-old female who is presenting for her annual gynecological exam.
She has a history of UTIs and is currently taking aspirin 81 mg daily, allergy medication as needed, Tums as needed with meals, and melatonin 3 mg as needed at night.
Her physical examination is unremarkable.
Differential Diagnosis

Normal variant
UTI
Pelvic inflammatory disease (PID)
Endometriosis
Ovarian cyst
Plan

The patient will have a urine culture to rule out a UTI.
She will be instructed to continue taking her current medications.
She will be scheduled for a pelvic ultrasound to rule out any structural abnormalities.
She will be counseled on the importance of regular gynecological exams and preventive care.
Reflection Notes

I would have liked to have had more information about the patient's sexual history, including the number of sexual partners she has had and whether she has ever been tested for sexually transmitted infections (STIs).
I would also have liked to have had more information about the patient's menstrual history, including the length of her menstrual cycles, the amount of bleeding, and any associated symptoms.
With more information, I would have been able to make a more accurate diagnosis and develop a more appropriate treatment plan.

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