Select a patient that you examined during the last four weeks as a Nurse Practitioner. Select a female patient with common endocrine or musculoskeletal conditions, Evaluate differential diagnoses for common endocrine or musculoskeletal conditions you chose .With this patient in mind, address the following in a SOAP Note:
Subjective: What details did the patient provide regarding or 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 appointment with the provider, as well as a rationale for this treatment and management plan.
Reflection notes: What would you do differently in a similar patient evaluation? And how can you relate this to your class and clinical readings.
References
Schuiling, K. D., & Likis, F. E. (2013). Women’s gynecologic health (2nd ed.). Burlington, MA: Jones and Bartlett Publishers.