Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages To Order 5-10 Pages Description/Paper Instructions
Week 3 SOAP Note
September 15, 2020
SUBJECTIVE DATA:
Patient Initials: E.G. Age: 38 Gender: F
Chief Complaint (CC): Requesting contraceptive options..
History of Present Illness (HPI): 38 year old female presenting to the clinic today to discuss contraceptive options. She states that she is not interested in having more children but her new partner has never fathered a child. Has one sexual partner, doesn’t use condoms. States have concerns with using the Plan B pill too often and think it has caused her menstrual cycle to become irregular. States she is interested in the Mirena IUD.
Medications:vitamin c
Allergies: NKA
Past Medical History (PMH): exercise-induced asthma, migraines, and IBS.
Past Surgical History (PSH): tonsils as a child.
OB/GYN History:
Menstrual History:
- Age at menarche: 13
- LMP: Sep. 10 2020
- Menstrual Pattern: irregular
- Duration of flow: 6 days
- Amount of flow: heavy
- Associated pain with menses: cramping with her menses and small blood clots
- Intermenstrual bleeding: irregular due to using the Plan B pill
- Menopause: NA
Contraception:
- Current method and satisfaction: no real contraceptive, using the Plan B pill when has intercourse to prevent pregnancy
- Previous methods, complications, and reasons for discontinuation-Was on the birth control pill but recently has new sex partner 3 months ago and had been a year before him so had no need to continue the pill.
Cervical and vaginal cytology:
- Most recent Pap: August 2020
- History of abnormal pap smears: none
Infections:
- No history of STIs, vaginitis, or PID
Personal/Social History: EG denies alcohol and drug use. Has had 2 sexual partners, a new partner within 3 months. Has five children. She works at the local school as a PARA. She tries to exercise three times a week and likes to attend Zumba. Uses a seatbelt, takes vitamin c daily, no firearms in the home.
Immunization History: Current on her vaccines. She states that she had her annual influenza vaccination as required by her job in October.
Significant Family History: maternal grandmother is alive with dementia, while her maternal grandfather is alive with COPD. Her paternal grandparents are both deceased due to an automobile accident. Her mother is alive with osteopenia and fibromyalgia, and her dad is alive with a history of skin cancer (basal cell). has one older sister with no medical problems and one younger brother with no reported medical problems.
Review of Symptoms:
General: Denies fever, fatigue, unexpected weight changes, decreased energy, chills
Skin: eczema due to weather, no other rashes or bruising, warm to touch
HEENT: Denies vision changes, seeing spots, photophobia, itchy/watery, denies hearing loss, vertigo, nasal congestion, sore throat
Neck: supple without adenopathy
Breasts: soft, fibrocystic changes bilaterally, without masses, dimpling or discharge
Respiratory: denies shortness of breath, cough, wheezing
Cardiovascular/Peripheral Vascular: denies edema, syncope, palpitations, no history of arrhythmias, orthopnea or chest pain
Gastrointestinal: no nausea, vomiting, or abdominal pain, BS active on all 4 quadrants, no constipation, no blood in the stool
Genitourinary: denies dysuria, hematuria, urinary frequency, urgency, incontinence, nocturia
Genitourinary-reproductive: complains of heavy periods with clots, some pelvic pain with menses
Musculoskeletal: denies back pain, body aches, joint stiffness, muscle weakness
Psychiatric: denies depression, suicidal thoughts, hallucinations, poor concentration
Neurological: denies any headaches, dizziness, numbness, tingling, memory loss, confusion, speech problems
Hematologic: no bruising, bleeding tendencies
Endocrine: no heat intolerance, cold intolerance, hot flashes, hirsutism
Allergic/Immunologic: no known allergies
OBJECTIVE DATA:
Physical Exam:
Vital Signs: 98.0 T, 18, 99% on RA, 68, 118/72, Height: 5’ 7” Weight 148 (BMI 23.1)
General: Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately, well groomed, clean nails, appears comfortable
HEENT: normocephalic/atraumatic, hair evenly distributed, PERRLA. EOMs intact. No conjunctival
Neck: Trachea midline, no palpable lymph nodes or thyroid enlargement/masses noted
Chest: normal, breast normal appearance, negative for nodules, masses, discharge, tenderness
Lungs: Respirations are regular, even, and unlabored. Lungs sound clear to auscultation in all lobes bilaterally. No abnormal breath sound noted.
Heart: : Rate and rhythm regular. Heart Sounds S1 S2. No S3 or S4 murmurs present, Capillary refill < 2 seconds, no edema
Abdomen: Abdomen flat; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly
Genital/Rectal: External genitalia has normal appearance. No redness, rashes, or lesions noted
Vulva/Labia Majora: normal
Cervix: firm, smooth, parous, without CMT
Uterus: RV, mobile, non-tender, approximately 10 cm,
Adnexa: without masses or tenderness
Musculoskeletal: no pain, all extremities equal strength
Neurological: Alert, oriented and co-operative
Skin: warm, dry, and intact, eczema rashes on hands
Lab/Diagnostic Tests and Results:
Hgb 13.5, Urine pH 6, Urine specific gravity 1.020, urine protein negative, urine ketones negative, urine blood negative, urine nitrate negative, urine urobilinogen normal, urine WBC negative, urine glucose negative
ASSESSMENT:
Differential Diagnosis (DDx):
- Dysmenorrhea: due to her having painful cramping with menses. Dysmenorrhea is a painful cramps that occurs with menstruation. Some alternative therapies are heating pads, regular exercise to decrease the symptoms, vitamins. Pharmacological treatments include NSAIDS (Schuiling & Likis, 2017).
- Menorrhagia is menstrual bleeding that lasts more than 7 days. It can also be bleeding that is very heavy. Have a menstrual flow with blood clots the size of a quarter or larger. Having a constant pain in the lower part of the stomach during periods (Centers for Disease Control and Prevention, 2017).
- Overuse of the Plan B pill. Using emergency contraception, like Plan B, comes with short-term effects like painful menstruation and nausea. Some women may experience spotting a few days after taking Plan B One-Step. Menstrual bleeding patterns are often irregular among women using progestin only contraception (Borreli, 2016).
Final Diagnosis: Well woman exam with concerns about contraceptives, that was her reason for coming to today’s appointment. Pap, gonorrhea, and chlamydia testing obtained.
PLAN: Educate about contraceptives, patient had her mind made up of having the Mirena IUD placed. Birth control discussed. We will schedule insertion once her period starts. Recommended to eat healthy, exercising regularly, and use of MVI/Calcium/Vitamin D. Educate on the use of condoms and not using the Plan B pill as a birth control.
References
Borreli, L. (2016). This Is What Happens When You Take Too Much Plan B. Retrieved from https://www.medicaldaily.com/repeated-use-morning-after-pill-plan-b-effects-breast-cancer-fertility-399556
Centers for Disease Control and Prevention. (2017). Heavy Menstrual Bleeding. Retrieved from: https://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html
Dragoman, M., Davis, A., & Banks, E. (2010). Contraceptive options for women with preexisting medical conditions. Journal of Women’s Health, 19(3), 575–580.
Schuiling, K. D., & Likis, F. E. (2017). Women’s gynecologic health (3rd ed.). Burlington, MA: Jones and Bartlett Publishers.
RUBRIC
QUALITY OF RESPONSE NO RESPONSE POOR / UNSATISFACTORY SATISFACTORY GOOD EXCELLENT Content (worth a maximum of 50% of the total points) Zero points: Student failed to submit the final paper. 20 points out of 50: The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. 30 points out of 50: The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately. Elements of the required response may also be lacking. 40 points out of 50: The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples. The answer is complete. 50 points: The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples. No aspects of the required answer are missing. Use of Sources (worth a maximum of 20% of the total points). Zero points: Student failed to include citations and/or references. Or the student failed to submit a final paper. 5 out 20 points: Sources are seldom cited to support statements and/or format of citations are not recognizable as APA 6th Edition format. There are major errors in the formation of the references and citations. And/or there is a major reliance on highly questionable. The Student fails to provide an adequate synthesis of research collected for the paper. 10 out 20 points: References to scholarly sources are occasionally given; many statements seem unsubstantiated. Frequent errors in APA 6th Edition format, leaving the reader confused about the source of the information. There are significant errors of the formation in the references and citations. And/or there is a significant use of highly questionable sources. 15 out 20 points: Credible Scholarly sources are used effectively support claims and are, for the most part, clear and fairly represented. APA 6th Edition is used with only a few minor errors. There are minor errors in reference and/or citations. And/or there is some use of questionable sources. 20 points: Credible scholarly sources are used to give compelling evidence to support claims and are clearly and fairly represented. APA 6th Edition format is used accurately and consistently. The student uses above the maximum required references in the development of the assignment. Grammar (worth maximum of 20% of total points) Zero points: Student failed to submit the final paper. 5 points out of 20: The paper does not communicate ideas/points clearly due to inappropriate use of terminology and vague language; thoughts and sentences are disjointed or incomprehensible; organization lacking; and/or numerous grammatical, spelling/punctuation errors 10 points out 20: The paper is often unclear and difficult to follow due to some inappropriate terminology and/or vague language; ideas may be fragmented, wandering and/or repetitive; poor organization; and/or some grammatical, spelling, punctuation errors 15 points out of 20: The paper is mostly clear as a result of appropriate use of terminology and minimal vagueness; no tangents and no repetition; fairly good organization; almost perfect grammar, spelling, punctuation, and word usage. 20 points: The paper is clear, concise, and a pleasure to read as a result of appropriate and precise use of terminology; total coherence of thoughts and presentation and logical organization; and the essay is error free. Structure of the Paper (worth 10% of total points) Zero points: Student failed to submit the final paper. 3 points out of 10: Student needs to develop better formatting skills. The paper omits significant structural elements required for and APA 6th edition paper. Formatting of the paper has major flaws. The paper does not conform to APA 6th edition requirements whatsoever. 5 points out of 10: Appearance of final paper demonstrates the student’s limited ability to format the paper. There are significant errors in formatting and/or the total omission of major components of an APA 6th edition paper. The can include the omission of the cover page, abstract, and page numbers. Additionally the page has major formatting issues with spacing or paragraph formation. Font size might not conform to size requirements. The student also significantly writes too large or too short of and paper 7 points out of 10: Research paper presents an above-average use of formatting skills. The paper has slight errors within the paper. This can include small errors or omissions with the cover page, abstract, page number, and headers. There could be also slight formatting issues with the document spacing or the font Additionally the paper might slightly exceed or undershoot the specific number of required written pages for the assignment. 10 points: Student provides a high-caliber, formatted paper. This includes an APA 6th edition cover page, abstract, page number, headers and is double spaced in 12’ Times Roman Font. Additionally the paper conforms to the specific number of required written pages and neither goes over or under the specified length of the paper. GET THIS PROJECT NOW BY CLICKING ON THIS LINK TO PLACE THE ORDER
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