To prepare:

By Day 1 of this week, you will be assigned to a specific case study scenario for this Discussion. Please see the “Course Announcements” section of the classroom for your case study assignment from your Instructor.

Review the Learning Resources for this week and pay close attention to the media program related to the basic microscope skills. Also, consider re-reviewing the media programs found in Week 1 Learning Resources.

Carefully review the clinical guideline resources specific to your assigned case study.

 American College of Obstetricians and Gynecologists (ACOG)Links to an external site.. (2020).  https://www.acog.org/

American Nurses Association (ANA)Links to an external site.. (n.d.). https://www.nursingworld.org/

Centers for Disease Control and Prevention. (CDC)Links to an external site.. (n.d.). https://www.cdc.gov/

HealthyPeople 2030. (2020). Healthy People 2030 FrameworkLinks to an external site.. https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2030/Framework

The American Association of Nurse Practitioners (AANP)Links to an external site.. What’s happening at your association. (2020). https://www.aanp.org/

Use the Focused SOAP Note Template attached to support Discussion. Complete a FOCUSED SOAP note and critically analyze this and focus your attention on the diagnostic tests. Please post your SOAP note. This will help you develop your differential diagnosis and additional questions.

Assignment:

Please post your FOCUSED SOAP NOTE with your differential diagnosis. 

Include the additional questions (additional questions ONLY related to the HPI/CC) you would ask the patient. Be sure to include an explanation of the tests you might recommend, ruling out any other issues or concerns and include your rationale. Be specific and provide examples.

Note: **Your differential diagnosis, additional questions, additional diagnostic tests and rationales are what this assignment and grading is focused on. Your critical thinking for this assignment

Case Study:

Elaine Goodwin is a 38-year-old G5 P5 LC 6 presenting to your 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. Her medical history is remarkable for exercise-induced asthma, migraines, and IBS. Her surgical history is remarkable only for tonsils as a child. Her social history is negative for alcohol, tobacco, and recreational drugs.  She has no known drug allergies and takes only vitamin C. Hospitalizations were only for childbirth. Family history reveals that her 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). Elaine has one older sister with no medical problems and one younger brother with no reported medical problems.  

· Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 P 68  

· HEENT:  wnl  

· Neck: supple without adenopathy  

· Lungs/CV: wnl  

· Breast: soft, fibrocystic changes bilaterally, without masses, dimpling or discharge  

· Abd: soft, +BS, no tenderness  

· VVBSU: wnl, except 1st degree cystocele  

· Cervix: firm, smooth, parous, without CMT  

· Uterus: RV, mobile, non-tender, approximately 10 cm,  

· Adnexa: without masses or tenderness