NURS 6551 Week 3 Soap note ob- gynecology 2022 update

Subjective: What details did the patient provide regarding her personal and medical history? Objective: What observations did you make during the physical assessment? Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why? Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Reflection notes: What would you do differently in a similar patient evaluation? HPI: A.M, a 20-year-old Caucasian female came to the clinic with C/O bumps at her private part which she noticed 5 days ago while taking a shower. She denies any fever chills or any pain, itching or discharge at site. She has not tried any treatment other than applying warm compress at site with no effect. She reports severity as mild but is extremely anxious as she is in sexual relationship with a new partner for a month. Medications: Depaprovera shot Allergies: NKDA. No known food allergies Past Medical History (PMH): None, no h/o blood transfusion Past Surgical History (PSH): None Sexual/Reproductive History: Menarche at the age of 13, periods regular, LMP on 12/1/18, sexually active from the age of 16, had 2 partners in the past, sexually active with current partner for a month, nulligravid, partner uses condom most of the time, but times miss to use it. Personal/Social History: She is a college student, active in sports, uses alcohol and tobacco occasionally, no intravenous drug usage Immunization History: All immunizations up to date according to the age, had 2 vaccine of HPV, flu shot on 10/25/2018.