Comprehensive History and Physical
- Reflect on your practicum experience and select a female patient whom you have examined with the support and guidance of your Preceptor.
- Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, and treatment and management plan, and education strategies and follow-up care.
- What additional considerations might you think about if your patient was pregnant or just delivered?
- Use the “Guidelines for Comprehensive History and Physical SOAP Note” document found in this week’s Learning Resources to guide you as you complete this Assignment.
Assignment:Write an 8- to 10-page Comprehensive Well-Woman Exam that addresses the following:
- Age, race and ethnicity, and partner status of the patient
- Current health status, including chief concern or complaint of the patient
- Contraception method (if any)
- Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)
- Review of systems
- Physical exam
- Labs, tests, and other diagnostics
- Differential diagnoses
- Management plan, including diagnosis, treatment, patient education, and follow-up care
- Provide evidence-based guidelines to support treatment plan. Note: Use your Learning Resources and evidence from scholarly sources from your personal search to support your treatment plan of care.
Reflect on some additional factors for your patient:
- What are the implications if your patient was pregnant or just delivered?
- What are implications if you have observed or know of some domestic violence? Would this change your plan of care? If so, how?
Use your Learning Resources and evidence from scholarly sources from your personal search to support your reflection.