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.
Write an 8- to 10-page comprehensive soap Note paper on Abnormal Uterine Bleeding , 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
Labs, tests, and other diagnostics
Management plan, including diagnosis, treatment, patient education, and follow-up care.