Potential Diseases and Medical Conditions in Women Assignment
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Order Number
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636738393092 |
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Type of Project
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ESSAY
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Writer Level
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PHD VERIFIED
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Format
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APA
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Academic Sources
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10
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Page Count
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3-12 PAGES
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Instructions/Descriptions
Potential Diseases and Medical Conditions in Women Assignment
Assignment 2: Comprehensive Well-Woman Exam
For a wide variety of medical conditions, early detection of the problem enables timely and more effective treatment. Annual well-woman exams are among the best tools available for health care professionals to identify potential diseases and medical conditions in women.
Advanced nurse practitioners can play an active role in these important visits. This role can include a physical examination as well as collection of details about such factors as nutrition habits, sexual activity, stress, and more. By participating in comprehensive well-woman exams, advanced nurse practitioners can help patients engage in preventative health.
Photo Credit: Teodor Lazarev / Adobe Stock
For this Assignment, you will complete your well-woman exam using a focused note format in which you will gather patient information, relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc.
Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using SAFE ASSIGN.
Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.
To prepare:
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?
Use your Learning Resources and evidence from scholarly sources from your personal search to support your reflection.
Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm).
Note: Your Comprehensive Well-Woman Exam Assignment must be signed by Day 7 of Week 10.
Jodi clarmont
Patient ID:119531646DOB:1/4/1981Sex:FAccount No.:
Encounter ID:262700526Encounter Date:07/29/2022
Encounter Type: Office Visit
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| SUBJECTIVE: |
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| Chief Complaint: |
Established care. Physical and well-woman visit |
| History Of Present Illness: |
The patient is a 41-year-old female who presented for physical and well-woman care. The patient is new in the area, she moves from Michigan state. She has a mood disorder, and is experiencing insomnia, multiple surgery, and digestive issues. The patient was very obese, for which she underwent bariatric surgery. The patient c/o BLE cramping and BUE pain. She needs a psychiatrist in the area. Will need a cardiologist to consult due to a family history of heart disease? Multiple chronic health issues are controlled with medications. Rates bilateral knee pain as 4/10. |
| Medical History: |
Sphincter of Oddi dysfunction Pancreatitis liver problems Colonoscopy in 2015 Colonoscopy in 1017, repeated in 2020 Sleep apnea Insomnia Depression Panic attacks Mood disorder |
| Surgical History: |
Pancreatic surgery in 2020 Bariatric surgery in 2018 Hysterectomy in 2012 Cervix removed Breast implant silicone |
| Gynecological History: |
Hysterectomy in 2012, Cervix removed, Breast implant silicone |
| Family History: |
Her great grandfather; had colon cancer Father; heart failure Mother; hyperlipidemia and thyroid disease Sibling; Healthy, no health issues |
| Social History: |
| She drinks I cup of coffee a day a history of 20 years pack smoker-she quit smoking one month ago and started Chantix 1 month ago. The patient denies alcohol intake and the use of illicit drugs. She has used glasses since 2022 and sees an eye doctor. Will need a dentist referral for wisdom teeth removal. She eats 3-5 meals on the go. She sees a psychiatrist in Azle, texas. |
| Smoking Status: Former Smoker |
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| Allergies: |
Trazodone Tramadol Cipro |
| Current Medications: |
Venlafaxine 150mg ER bid alprazolam 0.25mg daily as needed Hyoscyamine 0.125mg 1 po QID Ondansetron 4mg 1 po as needed |
| Review of System: |
| Constitutional: Denies weight loss, fever, chills, weakness, or fatigue. |
| Head: Denies headache, lightheadedness, or vertigo |
| Neck: Denies pain, stiffness, or tenderness. |
| Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. |
| Ears: Denies hearing loss, tinnitus, pain, vertigo, or use of an assistive hearing device. |
| Nose: Denies sneezing, congestion, runny nose, discharge, obstruction, epistaxis, or sinus issues |
| Mouth: Admit she needs to see the dentist for wisdom teeth removal |
| Throat: Denies sore throat, hoarseness, and dysphagia. |
| Cardiovascular: Denies chest pain, chest pressure, chest discomfort, palpitations, edema, or claudication |
| Respiratory: Denies cough, sputum, SOB, chest congestion, Wheezing, Phlegm, or hemoptysis |
| Gastrointestinal: Admit history Sphincter of Oddi dysfunction, pancreatitis, and liver problems |
| Genitourinary: Denies nocturia, dysuria, incontinence, frequency, urgency, or blood in the urine |
| Musculoskeletal: Admit bilateral knee pain |
| Integumentary (Skin and/or Breast): Denies rash, itching, abnormal lesions or skin problems |
| Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. |
| Psychiatric: Admit depression and panic attacks. The patient sees a psychiatrist pcp |
| Endocrine: Admit pancreatitis. Denies Excessive appetite, Excessive thirst, Heat intolerance, Cold intolerance |
| Hematologic/Lymphatic: Denies anemia, bleeding, or bruising. No enlarged nodes. No history of splenectomy |
| Allergic/Immunologic: Denies history of asthma, hives, eczema, itching, nasal congestion, rash, rhinitis, environment |
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| OBJECTIVE: |
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| Vital Signs: |
| Height: 64.00 in |
| Weight: 183.00 lbs |
| BMI: 31.41 |
| Blood Pressure: 114/80 mmHg |
| Temperature: 97.90 F |
| Pulse: 81 beats/min |
| Resp. Rate: 16 |
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| Physical Exam: |
| Constitutional: A 41-year-old well-developed, well-nourished, female who is alert, oriented, and cooperative. She is a good historian and answers questions readily and appropriately. She appears to be in no acute distress. |
| Ears, Nose, Mouth, and Throat: Eyes: PERRLA, EOM’s full, conjunctivae clear, fundi grossly normal, Started using since 2022, ear: EAC’s clear, TM’s normal, Throat: clear, no exudates, Neck: supple, adenopathy, no thyromegaly, no carotid bruits |
| Cardiovascular: Cardiologist consult; family history of heart disease |
| Chest/Breasts: History silicone breast implant |
| Heart: RRR, no murmur, no gallops, or rubs |
| Gastrointestinal (Abdomen): History of Pancreatitis, |
| Genitourinary: no Burning/painful urination, Frequency, Urgency, Night time urination, Blood in the Urine |
| Musculoskeletal: The pat is present with bilateral knee pain |
| Skin: Warm and dry, rashes or abnormal lesions, |
| Extremities: Full ROM without deformities; no clubbing, edema, or cyanosis |
| Neurological/Psychiatric: The patient presented with depression and panic attacks. She sees a psychiatrist |
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| ASSESSMENT: |
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| Assessments: |
| ICD-10 Assessments: |
| Multiple chronic health issues |
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| PLAN: |
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| Care Plan: |
New patient labs work order today. Advise on Mammogram to be done Advise on a healthy diet and exercise to reduce the risk of cardiovascular disease Weight loss to prevent obesity Start gabapentin 600mg po at bedtime Vitamin B12 5000mg Refill needed medications today Cardiologist referral Psychiatrist referral |
| Patient Instructions: |
Take medication as prescribed |
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| ___________________________ Date: _________ |
| [Provider]: Jackie Thomas, APRN
Learning Resources
Fowler, G. C. (2019). Pfenninger and Fowler’s Procedures for Primary Care (4th ed.). Elsevier.
Section 10, “Obstetrics”
Chapter 162, “Dilation and Curettage” (pp. 1093–1099)
Fanslow, J., Wise, M. R., & Marriott, J. (2019). Intimate partner violence and women’s reproductive health. Obstetrics, Gynecology & Reproductive Medicine, 29(12), 342–350. |
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