When was her last gyn exam?and what were results of tests

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Reference no: EM133598673

Assignment: Advanced Nurse Practice in Reproductive Health Care

Complete a focused soap note with your primary diagnosis. Include the additional questions (additional questions ONLY related to the HPI/CC) you would ask the patient and explain your reasons for asking the additional questions. Then, explain the types of symptoms you would ask. Be specific and provide examples. (Note: When asking questions, consider sociocultural factors that might influence your question decisions.)

Based on the preemptive diagnosis, explain which treatment options and diagnostic tests you might recommend.

What methods would be appropriate for Elaine???Charlene Baja is a 22-year-old G0 P0 L0 presents to the clinic today for discharge for 1 week. She denies any other symptoms. She states her boyfriend recently found out he was positive for gonorrhea. She states she is 10 weeks pregnant. She denies any other partners besides him. ?Her medical history is?remarkable for anxiety and depression. ?Her surgical history?is unremarkable. Her social history includes social?alcohol, but she denies tobacco and any recreational drugs.? She has no known drug allergies and takes a multivitamin daily. Her health history?reveals that her mother is alive with breast cancer in remission and hypothyroidism. Her paternal grandfather is alive with prostate cancer. Her sister has type 1 diabetes as well. Her father has HTN, diabetes type 2, and hyperlipidemia. ?Charlene has one brother with no medical history.

1. Height 5' 5"?Weight?148?(BMI 24.6),?BP 132/68 P?62
2. HEENT:? WNL
3. Neck: lymph nodes grossly normal
4. Lungs/CV: Chest is clear to auscultation bilaterally, normal respiration, rhythm, and depth upon exam
5. Breast: normal breast exam
6. Abd: WNL
7. VVBSU: WNL
8. Cervix: firm, smooth, yellow watery discharge in large amount present. Pain on cervical motion.
9. Uterus: RV, mobile,?non-tender
10. Adnexa: WNL

Task

Question I. Has she used or tried any treatments so far?

Question II. When did she find out about her partner's positive gonorrhea status?

Question III. When was her last gyn exam?and what were the results of the tests?

Question IV. Has she had any STD testing in the past?

Question V. Is she concerned with any other STDs?

She requests STD testing for any other diagnoses that could cause vaginal discharge.

Question I. What are your next steps/considerations?

Question II. What teaching should you do?

Question III. What methods would be appropriate for Elaine?

Reference no: EM133598673

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