Reference no: EM133735193
INSTRUCTIONS and REQUIREMENTS
Nursing assigment for women's heath NP
Comprehensive H&P note: ( Can be either OB or GYN focused)
First episodic note: ( OB focused)
Second episodic note: ( Gyn focused)
Students are expected to complete and submit:
ONE comprehensive, new patient visit: H&P
ONE Problem visit
ONE OB Visit (different template-posted separately)
The H&P Case Study must focus on the care of a patient that you have seen during your clinical practicum. Please follow the template below.
Please complete the template according to the type of visit. For PROBLEM VISIT, you should only complete the relevant review of systems and relevant physical exam.
Please indicate the pertinent positives and negatives that led to your diagnosis. You must list two other differential diagnoses that were ruled out based on history and physical exam.
Your plan of care should be based on current evidence or relevant guideline. If an alternate plan of care was selected, please note an explanation for the deviation and note the current guideline/recommendation.
Please list at least one current reference, citing in APA format.
During your case presentations with your preceptor, please be prepared to present:
a brief history about your patient's background, CC & HPI (presenting signs & symptoms), brief significant history pertinent only to diagnosis, significant parts of the physical exam. Explain the differential diagnosis and associated positive and negative findings. Indicate the final diagnosis and plan of care (diagnosis and treatment).
Date of Visit:
Chief Complaint:
History of Present illness:
PMH:
GYN History:
Menstrual:
OB:
Sexual (including partners, contraception, STI hx)
PSH:
Family HX:
Social HX: smoke, vape, ETOH, drug
IPV Screen:
Depression Screen:
Health Promotion/Screenings/Immunizations:
Allergies: Medications/foods/environmental
Current Medications: indicate Dose, Route, Frequency
Review of Systems:
General:
Skin:
HEENT: Head:
Eyes:
Ears:
Nose:
Throat:
Breasts:
Respiratory:
Cardiovascular:
Gastrointestinal:
Genitourinary:
Genital:
Peripheral Vascular:
Musculoskeletal:
Neurologic:
Hematologic:
Endocrine:
Psychiatric:
Physical Exam:
Vital Signs: Blood Pressure- P- RR- T- Height- Weight- BMI-
General:
Skin:
HEENT: Head:
Eyes:
Ears:
Nose:
Throat:
Neck:
Breasts:
Lungs:
Heart:
Abdomen:
Genitalia:
Rectal:
Extremities:
Musculoskeletal:
Neurological:
Pertinent Labs/Diagnostic Testing/Referrals:
Assessment/Plan:
Differential Diagnosis Pertinent Positive Pertinent Negative
Diagnosis # 1 (this is the final/primary diagnosis)
Plan listed here
Include one Health Promotion/Anticipatory Guidance Diagnosis
Plan for screening (ie mammo, colonoscopy, cholesterol) or prevention (immunizations) or management of BMI or risk behavior (smoking cessation, sexual risk counseling)
Diagnosis # 2
a. Plan listed here
b.
c.
Diagnosis # 3
Plan listed here
RTC/Follow up plan:
References
Attachment:- Template for HP OBGYN.rar