Case Study/ Soap Note : See attachment  | Nursing

See attachment  NURS684Week1DiscussionCase2.pdf Case Scenario 2: Complete the charts and answer the case scenario. 2018 USPSTF Guidelines 2021 ACS Guidelines Age 21-24 Age 25-29 Age 30-65 Age 65 and older American Cancer Society Recommenda1ons for the Early Detec1on of Cancer in Average-Risk, Asymptoma1c Adults CANCER SITE POPULATION TEST OR PROCEDURE RECOMMENDATION SUMMARY Breast Cervix Colorectal Endometrial Ellen is a 35-year-old female whose latest Pap smear result reports HSIL with positive HPV. Ellen reports no h/o of STIs or previous abnormal Pap smear results. She had only two previous Pap tests 7 and 14 years ago. Ellen is G1P0 with a TAB at age 25. She and her partner are undecided whether they want to have children. She has been monogamously married to a female partner for the last 5 years, but she considers herself bisexual and has previously engaged in sexual activities with males and females. Ellen denies any significant medical history or current health problems. Her LMP was 5 days ago and her VS are WNL. Her BMI is 24.7. Her pregnancy test is negative. Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note. 1. Subjective: a. What other relevant questions should you ask regarding the HPI? b. What other medical history questions should you ask? c. What other social history questions should you ask? 2. Objective: a. What other point of care testing (POCT) would you perform or order for this patient? Why? 3. Assessment/ Diagnosis: a. What would be an appropriate diagnosis for her? Explain Ellen’s Pap smear results (pathophysiology) and the action(s) that will be taken next to follow up this abnormality, including patient education (explain the procedure to the patient). 4. Plan: a. What will you prescribe for this patient? Why? b. What patient education is important to include for this patient? c. Is there any education or advice you would give to Ellen regarding her current female partner? d. What pharmacological and non pharmacological education and advice can you give Ellen to help with her HSIL condition? Please refer to evidence-based guidelines to support your decision-making. SOAP NOTE FORMAT Subjective CC: HPI: Medications: Allergies: LMP: Gyn/OB history: PMH: Chronic Illness/ Major trauma: Family Hx: Social Hx: ROS - List the body systems and provide answers - (Don’t forget to include Gyn ROS) - You can include questions here that you’d like to ask the patient Objective Data General- provide findings VS List body systems- provide findings - (Don’t forget Gyn System) - (You can include answers here to questions posed in the prompt) Include POCT (Point of Care testing) not labs that you will send to the laboratory Assessment/ Diagnosis Include the ICD10 code DDX Plan Diagnostic tests Lab Tests Treatment Medication Referrals Education Health Maintenance Follow up Prompt Questions (You can include answers here that is asked in the prompt)