Comprehensive Patient Assessment

To prepare: • 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, treatment and management plan, as well as education strategies and follow-up care. Comprehensive Patient Assessment When completing practicum requirements in clinical settings, you and your Preceptor might complete several patient assessments in the course of a day or even just a few hours. This schedule does not always allow for a thorough discussion or reflection on every patient you have seen. As a future advanced practice nurse, it is important that you take the time to reflect on a comprehensive patient assessment that includes everything from patient medical history to evaluations and follow-up care. For this Assignment, you begin to plan and write a comprehensive assessment paper that focuses on one female patient from your current practicum setting. To complete: Write an 8- to 10-page comprehensive paper that addresses the following: 1. General patient information a. Age b. Race/ethnicity c. Partner status 2. Current health status a. Chief concern/complaint and history of present illness (include a complete symptom analysis of chief complaint(s) utilizing OLDCART for a sick/problem-focused visit) b. Last menstrual period or year of menopause c. DES exposure (if born between 1948 and 1971) d. Sexual activity status e. Barrier prevention f. Sexual preference g. Satisfaction with sexual relations 3. Contraception method (if any) 4. Patient history a. Past medical history • Major medical events (including pediatric events) • Psychological and mental health • Surgeries and/or hospitalizations if pertinent • Medications, including prescriptions, over-the-counter medications, home and herbal remedies, calcium, and vitamin supplements • Allergies, including drug, food, and environment • Health maintenance/screenings, including results of patient’s last Pap and mammogram as appropriate, as well as previous vaccinations (HPV, MMR, hepatitis B, last dT, and pneumovax/influenza as appropriate) b. Family medical history c. Gynecologic history • Nullipara vs. multipara • History of sexually transmitted infections and sexually transmitted diseases • Menarche and menstrual patterns • Menopause or peri-menopausal symptoms (if applicable) d. Obstetric history • Gravida and parity status (TPAL) • Pregnancy history, including history of preterm or low birth weight, other pregnancy complications, history of sexually transmitted diseases, and any pertinent negatives e. Personal social history (as appropriate to the current problem) • Cultural background • Education and economic condition • Abuse history including assault and forced sex (past and current) • Occupational health patterns • Environment • Current health habits and/or risk factors • Substance use (must include for every patient) • Tobacco including frequency and longevity • Alcohol including results of CAGE unless patient has never used • Recreational drug use (past and current) • Exercise and physical activity • Diet and nutrition • Sleep • Caffeine 5. Review of systems (ROS) a. Must include reproductive system as well as other pertinent systems (systems relevant to HPI should be included under HPI) 6. Physical exam a. General exam, including vital signs, height, weight, and BMI on every patient b. Physical exam focused on episodic complaint (include numbers of weeks gestation, fundal height, and fetal heart tones for OB patients) 7. Labs, tests, and other diagnostics a. Pertinent labs, test, and other diagnostics (include routine tests such as triple screen and urine dip for OB patients) 8. Differential diagnoses a. Explain why this set of differential diagnoses should be considered and why each diagnosis should be ruled in or ruled out. 9. Management plan a. Diagnosis b. Treatment c. Patient education d. Follow-up care 10. Health Promotion 11. Disease Prevention 12. Reflection (What would you do differently in a similar patient evaluation?) Patient’s History: 30 year old African American female presents to the office for annual gynecology examination and complained of cottage cheese vaginal discharge for a week. The patient reported vaginal soreness and itching with odorless cottage cheese discharge. The patient stated that she is not certain of cause of the itching. She reported that she completed 7 days Amoxicillin treatment for upper respiratory infection 9 days ago. The patient stated that she is sexually active with husband of 5 years and they have a 5-year-old son together. She reported that she is on intrauterine device for contraception and does not use condom during sexual intercourse with her husband. Patient reported her last menstrual cycle was 12/20/2019 and lasted for 4-5 days. Patient reported she tried douching to help relieve the itching and discharge, but has not noted any improvement. The patient however denies fever, chills, flank pain, painful urination, pelvic, or abdominal pain. Purpose Statement Primary Diagnosis: Vulvovaginal candidiasis Differential Diagnosis: Bacterial vaginosis (BV) Trichomoniasis Gonorrhea NOTE: Pls follow the attached paper example details.

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