Complete the Gynecologic SOAP Note: (Attached)

 

ASSESSMENT:

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines. Explain what the DD is, use references to explain and tell how you ruled in or ruled out the DD. Include a reference citation for the DD.

 

Primary diagnosis: Fibroadenoma. (Define what you believe is the most important diagnosis)

 

Differential diagnosis: Lipoma and Malignant Neoplasm of Breast.

 

Diagnostic Tests and Results:  

Explain which diagnostic tests and treatment options you would recommend for your patient and explain your reasoning. (Focus your attention on the diagnostic tests)

 

PLAN:

Include referrals and therapeutic interventions (pharmacological & non-pharmacological), disposition/follow up instructions, and education. 

Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. 

 

Reflection:

The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?

Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background). Also, share with your colleagues your experiences as well as what you learned from these experiences.

 

References:

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

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