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Tag: Clinical Nursing & Patient Care

  • [Solved] how a comprehensive clinical assessment presents a unique opportunity for intervention in the psychotherapeutic context.

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    Discuss how a comprehensive clinical assessment presents a unique opportunity for intervention in the psychotherapeutic context. The student must answer the graded discussion with a substantive reply to the graded discussion question(s)/topic(s) posted by the course instructor. Two scholarly sources…

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    Discuss how a comprehensive clinical assessment presents a unique opportunity for intervention in the psychotherapeutic context.

    The student must answer the graded discussion with a substantive reply to the graded discussion question(s)/topic(s) posted by the course instructor. Two scholarly sources references are required unless stated otherwise by your professor.

    Here are the categories of the new discussion rubric:

    Initial Post relevance to the topic of discussion, applicability, and insight. (20%)

    Quality of Written Communication Appropriateness of audience and words choice is specific, purposeful, dynamic, and varied. Grammar, spelling, punctuation. (20%)

    Inclusion of APNA standards essentials explored in the discussion as well as the role-specific competencies as applicable. (10%)

    Rigor, currency, and relevance of the scholarly references. (Use articles that are below 5 years). (20%)

    Peer & Professor Responses. The number of responses, quality of response posts. (20%)

    Timeliness of the initial post and the answers to the peers. (10%)

    – a year ago

  • [Solved] Draw a three-generation genogram of your family

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    Draw a three-generation genogram of your family. How do you think your family has contributed to your development and self-definition? The student must answer the graded discussion with a substantive reply to the graded discussion question(s)/topic(s) posted by the course instructor. Eastern Time. T…

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    Draw a three-generation genogram of your family. How do you think your family has contributed to your development and self-definition?

    The student must answer the graded discussion with a substantive reply to the graded discussion question(s)/topic(s) posted by the course instructor. Eastern Time. Two scholarly sources references are required unless stated otherwise by your professor.

    Here are the categories of the new discussion rubric:

    Initial Post relevance to the topic of discussion, applicability, and insight. (20%)

    Quality of Written Communication Appropriateness of audience and words choice is specific, purposeful, dynamic, and varied. Grammar, spelling, punctuation. (20%)

    Inclusion of APNA standards essentials explored in the discussion as well as the role-specific competencies as applicable.(10%)

    Rigor, currency,  and relevance of the scholarly references. (Use articles that are below 5 years). (20%)

    Peer & Professor Responses. The number of responses, quality of response posts. (20%)

    Timeliness of the initial post and the answers to the peers. (10%

    – a year ago

  • [Solved] Describe two cognitive techniques and two behavioral techniques

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    Describe two cognitive techniques and two behavioral techniques. In what types of situations would you choose each? The student must answer the graded discussion with a substantive reply to the graded discussion question(s)/topic(s) posted by the course instructor. Eastern Time. Two scholarly source…

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    Assignment Prompt & Instructions

    Describe two cognitive techniques and two behavioral techniques. In what types of situations would you choose each?

    The student must answer the graded discussion with a substantive reply to the graded discussion question(s)/topic(s) posted by the course instructor. Eastern Time. Two scholarly sources references are required unless stated otherwise by your professor.

    Here are the categories of the new discussion rubric:

    Initial Post relevance to the topic of discussion, applicability, and insight. (20%)

    Quality of Written Communication Appropriateness of audience and words choice is specific, purposeful, dynamic, and varied. Grammar, spelling, punctuation. (20%)

    Inclusion of APNA standards essentials explored in the discussion as well as the role-specific competencies as applicable.(10%)

    Rigor, currency,  and relevance of the scholarly references. (Use articles that are below 5 years). (20%)

    Peer & Professor Responses. The number of responses, quality of response posts. (20%)

    Timeliness of the initial post and the answers to the peers. (10%)

    – a year ago

  • [Solved] create a reply to the post using different scholarly references no oldr than 5 years old

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    **Quantitative Study** **Assessing the Impact of Telehealth on Blood Glucose Management Among Patients with Diabetes** In this study a systematic review and meta-analysis of randomized controlled trials (RCTs) was used. Multiple RCTs studied patients who received telehealth interventions against tho…

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    Assignment Prompt & Instructions

    **Quantitative Study**

    **Assessing the Impact of Telehealth on Blood Glucose Management Among Patients with Diabetes**

    In this study a systematic review and meta-analysis of randomized controlled trials (RCTs) was used. Multiple RCTs studied patients who received telehealth interventions against those who received traditional in-person diabetes care. The main finding was that Telehealth interventions significantly improved blood glucose management, evidenced by a standardized mean difference (SMD) of 0.20 (95% CI: 0.10–0.29; p < 0.001). The subgroup analysis revealed that U.S.-based studies together with veteran outpatient populations received the most significant benefits.

    **Qualitative Study**

    **Facilitators and Barriers of Health Behaviors in Patients With Type 2 Diabetes**

    The research included 25 patient interviews which were analyzed through thematic analysis. The research study found 18 subthemes that affect health behaviors. The study also found that self-efficacy together with outcome expectations and risk perception and social support acted as facilitators. The barriers to health behavior change included insufficient disease awareness together with low self-control and inadequate problem-solving abilities.

    **Comparison**

    The quantitative research analyzed telehealth interventions to determine their impact on blood glucose management. The statistical evaluation of data from multiple RTCs were used. The research included multiple studies which studied a wide range of patients. The study utilized quantitative blood glucose level measurements as its main assessment tool. Telehealth demonstrated measurable improvements in glycemic control. The research provided support for implementing telehealth as a part of diabetes management protocols. The qualitative research used thematic analysis of semi-structured patient interviews to investigate personal experiences that shape health behaviors in type 2 diabetes patients. 25 patients with type 2 diabetes were interviewed. The research revealed psychological and social factors affect health behaviors through qualitative insights about personal beliefs and experiences. The findings demonstrate that individualized interventions must address specific obstacles that each person faces.

    **Conclusion**

    The quantitative study demonstrates through empirical evidence that telehealth serves as an effective tool for blood glucose level management but the qualitative study reveals how personal and social factors affect patient behaviors. These studies demonstrate that diabetes management results improve when patients receive technological interventions together with personalized support..

    **References**

    Getie, A., Amlak, B.T., Ayenew, T. _et al._ Assessing the impact of telehealth on blood glucose management among patients with diabetes: a systematic review and meta-analysis of randomized controlled trials. _BMC Health Serv Res_ 25, 285 (2025). [https://doi.org/10.1186/s12913-025-12401-9](https://doi.org/10.1186/s12913-025-12401-9)

    Liu W, Zhang Q, Liu W. Facilitators and Barriers of Health Behaviors in Patients With Type 2 Diabetes: A Qualitative Study. Sci Diabetes Self Manag Care. 2025 Feb;51(1):47-63. doi: 10.1177/26350106241304421. Epub 2025 Jan 11. PMID: 39797650.

    – a year ago

  • [Solved] see below

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    In-depth study guidance and analytical solution covering see below.

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    Assignment Prompt & Instructions

    Full assignment prompt and step-by-step guidance are included in the downloadable solution file.

  • [Solved] Assigment .Apa seven . All instructions attached.

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    – a year ago **files (1)** – ## WritingAssignmentWeek1.docx **## WritingAssignmentWeek1.docx** Writing Assignment Week 1 **Exercise Instructions** The CMS considers patient engagement a quality metric for a learning healthcare system. ● Patient engagement is a major focal point of stage 2 MU of HER….

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    – a year ago

    **files (1)**

    – ## WritingAssignmentWeek1.docx

    **## WritingAssignmentWeek1.docx**

    Writing Assignment Week 1

    **Exercise Instructions**

    The CMS considers patient engagement a quality metric for a learning healthcare system.

    ●   Patient engagement is a major focal point of stage 2 MU of HER.

    ●   Patient Engagement in Health and Health Care Framework by Carman et al. presents different forms and levels of patient engagement across the healthcare system.

    ●   Institute for Patient- and Family-Centered Care recognizes the vital role families play by providing emotional, social, and developmental support, ensuring the health and well-being of all family members

    ●   The
    _Level of Engagement with Health Care_ framework considers the engagement, quality, and safety of mobile apps. Clinicians can identify trustworthy apps that serve the engagement of high-need, high-cost populations.

    **Consider content covered in chapter 5 concerning policy changes in the United States and the strategic plan needed to improve care and drive down cost through health information technology. Give at least 3 examples of an information technology policy change that has supported patient engagement.**

    Please note the grading rubric. The submission should be minimally 4 pages not counting the cover page and references.

    **5 references**

    **## WritingAssignmentWeek1.docx**

    Writing Assignment Week 1

    **Exercise Instructions**

    The CMS considers patient engagement a quality metric for a learning healthcare system.

    ●   Patient engagement is a major focal point of stage 2 MU of HER.

    ●   Patient Engagement in Health and Health Care Framework by Carman et al. presents different forms and levels of patient engagement across the healthcare system.

    ●   Institute for Patient- and Family-Centered Care recognizes the vital role families play by providing emotional, social, and developmental support, ensuring the health and well-being of all family members

    ●   The
    _Level of Engagement with Health Care_ framework considers the engagement, quality, and safety of mobile apps. Clinicians can identify trustworthy apps that serve the engagement of high-need, high-cost populations.

    **Consider content covered in chapter 5 concerning policy changes in the United States and the strategic plan needed to improve care and drive down cost through health information technology. Give at least 3 examples of an information technology policy change that has supported patient engagement.**

    Please note the grading rubric. The submission should be minimally 4 pages not counting the cover page and references.

    **5 references**

  • [Solved] evaluation

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    – a year ago **files (1)** – ## SummativeEvaluationFinal_ADNG1200_ClinicalI1.docx **## SummativeEvaluationFinal_ADNG1200_ClinicalI1.docx** **Level 1:** **Clinical Performance Evaluation- ADNG 1200 Clinical I** · Student will complete a self-evaluation of each student learning outcome below using…

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    – a year ago

    **files (1)**

    – ## SummativeEvaluationFinal_ADNG1200_ClinicalI1.docx

    **## SummativeEvaluationFinal_ADNG1200_ClinicalI1.docx**

    **Level 1:**
    **Clinical Performance Evaluation- ADNG 1200 Clinical I**

    · Student will complete a self-evaluation of each student learning outcome below using the criteria on the left found under each outcome. Briefly summarize, either in bullet point or paragraph form, your own evaluation of performance in each. Be specific, give examples.

    · In areas you identify as needing growth, provide specific strategies for improvement in your next clinical course.

    · Submit to the Clinical Performance Evaluation assignment folder in your clinical course by the assigned due date.

    | | |
    | — | — |
    | **HUMAN FLOURISHING**<br>**Apply knowledge and skills learned in the program to uphold patients’ right of self-determination**<br>**and promote holistic well-being of client and family.** |
    | **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
    | · Apply therapeutic communication skills in interactions with resident and family <br>· Recognize opportunities to connect with resident on an individual level<br>· Identify behaviors that threaten or protect resident rights and safety <br>●Utilize daily clinical paperwork as a framework to gather assessment data while respecting client rights and autonomy<br>●Work with resident to build rapport/trust prior to gathering data | |
    | **Objective Data:** Process Recording, Reflective Journals, Daily Clinical Paperwork, Daily Clinical Performance Grade | |
    | **NURSING JUDGMENT**<br>**Make judgments in practice, supported by evidence, that integrate nursing science in the provision of safe, quality care.** |
    | **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
    | ●Utilize daily clinical paperwork to record and prioritize daily assessment, Braden, and Morse fall findings<br>· Participate in post-clinical discussion of daily assessment findings and how these impact resident health and safety<br>●Utilize the EMR to accurately document care provided as appropriate<br>· Respect client privacy and feelings while gathering assessment data<br>· Takes time to listen to resident and allows them to express their needs and desires<br>· Reflects on the unique needs of the geriatric population during post-clinical discussion | |
    | **Objective Data:** Medication Concept Map, Geriatric Care Plan Concept Map, Daily Clinical Paperwork, Evolve Case Study/EAQ’s, Daily Clinical Performance Grade | |
    | **PROFESSIONAL IDENTITY**<br>**Implement one’s role as a nurse in a manner that reflects the ideals of the profession while developing an identity committed to evidence-based practice, in the provision of compassionate, culturally sensitive, holistic care to a diverse population.** |
    | **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
    | · Exhibit professional appearance and behavior (punctuality, uniform standards, equipment, etc.)<br>· Exhibit professionalism in interactions with team-members, peers, residents, and faculty<br>· Seeks faculty assistance in navigating professional situations unfamiliar to student | |
    | **Objective Data:** Reflective Journals, Daily Clinical Performance Grade | |
    | **SPIRIT OF INQUIRY**<br>**Examine the evidence that underlies clinical nursing practice to challenge the status quo, question underlying assumptions, and offer new insights to improve the quality of care for patients, families, and communities (NLN, 2010)..** |
    | **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
    | · Reflect on daily experience during post-clinical discussion <br>· Work with nursing faculty to review daily grading rubric feedback and make a plan for strategies for daily performance improvement<br>· Seeks out nursing faculty as questions arise | |
    | **Objective Data:** Reflective Journal #2, Daily Clinical Performance Grade | |

    **## SummativeEvaluationFinal_ADNG1200_ClinicalI1.docx**

    **Level 1:**
    **Clinical Performance Evaluation- ADNG 1200 Clinical I**

    · Student will complete a self-evaluation of each student learning outcome below using the criteria on the left found under each outcome. Briefly summarize, either in bullet point or paragraph form, your own evaluation of performance in each. Be specific, give examples.

    · In areas you identify as needing growth, provide specific strategies for improvement in your next clinical course.

    · Submit to the Clinical Performance Evaluation assignment folder in your clinical course by the assigned due date.

    | | |
    | — | — |
    | **HUMAN FLOURISHING**<br>**Apply knowledge and skills learned in the program to uphold patients’ right of self-determination**<br>**and promote holistic well-being of client and family.** |
    | **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
    | · Apply therapeutic communication skills in interactions with resident and family <br>· Recognize opportunities to connect with resident on an individual level<br>· Identify behaviors that threaten or protect resident rights and safety <br>●Utilize daily clinical paperwork as a framework to gather assessment data while respecting client rights and autonomy<br>●Work with resident to build rapport/trust prior to gathering data | |
    | **Objective Data:** Process Recording, Reflective Journals, Daily Clinical Paperwork, Daily Clinical Performance Grade | |
    | **NURSING JUDGMENT**<br>**Make judgments in practice, supported by evidence, that integrate nursing science in the provision of safe, quality care.** |
    | **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
    | ●Utilize daily clinical paperwork to record and prioritize daily assessment, Braden, and Morse fall findings<br>· Participate in post-clinical discussion of daily assessment findings and how these impact resident health and safety<br>●Utilize the EMR to accurately document care provided as appropriate<br>· Respect client privacy and feelings while gathering assessment data<br>· Takes time to listen to resident and allows them to express their needs and desires<br>· Reflects on the unique needs of the geriatric population during post-clinical discussion | |
    | **Objective Data:** Medication Concept Map, Geriatric Care Plan Concept Map, Daily Clinical Paperwork, Evolve Case Study/EAQ’s, Daily Clinical Performance Grade | |
    | **PROFESSIONAL IDENTITY**<br>**Implement one’s role as a nurse in a manner that reflects the ideals of the profession while developing an identity committed to evidence-based practice, in the provision of compassionate, culturally sensitive, holistic care to a diverse population.** |
    | **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
    | · Exhibit professional appearance and behavior (punctuality, uniform standards, equipment, etc.)<br>· Exhibit professionalism in interactions with team-members, peers, residents, and faculty<br>· Seeks faculty assistance in navigating professional situations unfamiliar to student | |
    | **Objective Data:** Reflective Journals, Daily Clinical Performance Grade | |
    | **SPIRIT OF INQUIRY**<br>**Examine the evidence that underlies clinical nursing practice to challenge the status quo, question underlying assumptions, and offer new insights to improve the quality of care for patients, families, and communities (NLN, 2010)..** |
    | **Expected Satisfactory Behaviors** | **Student Self-Evaluation** |
    | · Reflect on daily experience during post-clinical discussion <br>· Work with nursing faculty to review daily grading rubric feedback and make a plan for strategies for daily performance improvement<br>· Seeks out nursing faculty as questions arise | |
    | **Objective Data:** Reflective Journal #2, Daily Clinical Performance Grade | |

  • [Solved] learning experience

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    – Refer to the “Population-Focused Nurse Practitioner Competencies” in the Learning Resources, and consider the quality measures or indicators advanced practice nurses must possess in your specialty. – Refer to your “Clinical Skills Self-Assessment Form” you submitted in Week 1 and consider your str…

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    – Refer to the “Population-Focused Nurse Practitioner Competencies” in the Learning Resources, and consider the quality measures or indicators advanced practice nurses must possess in your specialty.
    – Refer to your “Clinical Skills Self-Assessment Form” you submitted in Week 1 and consider your strengths and opportunities for improvement.
    – Refer to your Patient Log in Meditrek; consider the patient activities you have experienced in your practicum experience and reflect on your observations and experiences.

    **In 450–500 words, address the following:**

    **Learning From Experiences**

    – Revisit the goals and objectives from your Practicum Experience Plan. Explain the degree to which you achieved each during the practicum experience.
    – Reflect on the 3 most challenging patients you encountered during the practicum experience. What was most challenging about each?
    – What did you learn from this experience?
    – What resources were available?
    – What evidence-based practice did you use for the patients?
    – What would you do differently?
    – How are you managing patient flow and volume?  How can you apply your growing skillset to be a social change agent within your community?

    **Communicating and Feedback**

    – Reflect on how you might improve your skills and knowledge and how to communicate those efforts to your Preceptor.
    – Answer these questions: How am I doing? What is missing?
    – Reflect on the formal and informal feedback you received from your Preceptor.

    – [\
    \
    PracticumExperiencePlan2.docx](https://www.sweetstudy.com/files/practicumexperienceplan2-docx-10287073 "PracticumExperiencePlan2.docx")
    – [\
    \
    PracticumExperiencePlan1.docx](https://www.sweetstudy.com/files/practicumexperienceplan1-docx-10287075 "PracticumExperiencePlan1.docx")

    – a year ago

  • [Solved] PowerPoint Presentation

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    Please provide a speak over PowerPoint presentation on the utilization of one of the Cognitive Behavioral Therapy (a nonpharmacological psychotherapy approach) for the diagnosis and treatment of a behavioral disorder of your choice based on the reading of the course material. Please include the foll…

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    Assignment Prompt & Instructions

    Please provide a speak over PowerPoint presentation on the utilization of one of the Cognitive Behavioral Therapy (a nonpharmacological psychotherapy approach) for the diagnosis and treatment of a behavioral disorder of your choice based on the reading of the course material.

    Please include the following slides in your presentation (you can use the sample provided)

    Title slide

    Intro slide

    Case scenario summary slide (patient name, diagnosis, background)

    Mental status assessment slide (perception, thought process, content of thought, judgment, insight, cognition)

    Selected therapy slide (Please include a description and the goals of the therapy of your choice)

    Selected therapy slide (Why did you select this therapy for your specific case study? )

    Expected outcomes (Include the outcomes that you expect your patient to accomplish)

    Conclusion slide

    Reference slide

    Include three scholarly sources references.

    Course Outcomes Relates to the Assignment

    Translate major theories from nursing and other disciplines to psychiatric practice.

    Integrate foundational and advanced specialty knowledge into clinical reasoning.

    Recognized the dynamic nature of advanced practice psychiatry nursing.

    Identify the tenets, benefits, and phases of group therapy.

    Understand the evolution and the assumption of family therapy.

    Understand the role of the psychiatric mental health advanced nurse practitioner as it relates with the scope of psychopathology.

    Defining the semiology, diagnostic, and treatment of behavioral and mental disorders.

    Understand, comparing various personality disorders, chronic and acute psychiatric decompensation presentations.

    Use of nonpharmacological interventions in the process of differential diagnosis and disease management.

    – a year ago

  • [Solved] 1 response DB Week 1

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    see attachment – a year ago **files (1)** – ## Week1DBresponse.pdf **## Week1DBresponse.pdf** Denise, a 19-year-old female presents to the clinic for an annual physical exam. She is G0P0, and presents with irregular menses only occurring every 3-4months apart within the past 2 years. She is sexually…

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    see attachment

    – a year ago

    **files (1)**

    – ## Week1DBresponse.pdf

    **## Week1DBresponse.pdf**

    Denise, a 19-year-old female presents to the clinic for an annual physical exam. She is
    G0P0, and presents with irregular menses only occurring every 3-4months apart within
    the past 2 years. She is sexually active and only using condoms occasionally. She is not
    on any other birth control methods. She denies any significant medical or surgical health
    history and denies any other current health problems. She has never had a Pap smear or
    any pelvic exam tests before today. Her pregnancy test is negative and her vital signs are
    all WNL.

    SOAP NOTE

    S – Subjective

    CC: "I want birth control and my periods are irregular."

    HPI:
    Denise is a 19-year-old G0P0 female presenting for her annual exam. She reports
    irregular menses occurring every 3–4 months for the past 2 years. She is sexually active
    and occasionally uses condoms. She denies any history of abnormal vaginal discharge,
    pelvic pain, or previous STIs. Denies fatigue, weight gain/loss, or hirsutism.

    Additional questions to ask:

    • When was your last menstrual period (LMP)?
    • Any recent changes in stress, weight, or exercise habits?
    • Any family history of PCOS, thyroid disorders, or reproductive issues?
    • Number of lifetime partners? Current partner status?
    • History of STI testing?
    • Desire for pregnancy in the next year?

    Medical History: Denies chronic illnesses, surgeries, or hospitalizations.

    Social History:

    • Home: Lives with parents.
    • Education: In college.
    • Alcohol/Drugs: Denies drug use, occasional alcohol socially.
    • Smoking: Denies.
    • Sexuality: Heterosexual, sexually active.
    • Contraception: Inconsistent condom use.

    O – Objective

    Vital Signs: WNL
    General: Alert, cooperative
    POCT:

    • Urine pregnancy test (Negative – already obtained)
    • Gonorrhea/Chlamydia NAAT (recommended)
    • TSH if concern for endocrine cause of irregular menses
    • Consider HbA1c or fasting glucose if PCOS suspected

    Pap smear: Not indicated at this time. According to USPSTF and ACOG guidelines,
    cervical cancer screening with Pap smear begins at age 21 regardless of sexual activity.
    She may have the option now if she consents, but it is not mandatory until age 21

    Pelvic exam: May perform if patient consents, especially for STI testing or symptoms

    A – Assessment

    Primary Diagnosis:

    • Irregular menses, likely secondary to an-ovulation (ICD-10: N92.6 – Irregular
    menstruation, unspecified)

    Differential Diagnoses:

    • Polycystic Ovary Syndrome (PCOS) – Consider due to menstrual irregularity and
    adolescent age

    • Hypothyroidism – Should rule out with TSH if symptomatic

    P – Plan

    Pharmacologic:

    • Prescribe Combined Oral Contraceptive Pill (COCP): e.g., Ethinyl estradiol 30
    mcg/norgestimate 0.25 mg PO daily, 28-day pack. 12-month supply, 0 refills

    o Rationale: Effective birth control and cycle regulation
    o Consider patient preference: patch, ring, or progestin-only if COCP contraindicated

    Non-Pharmacologic:

    • Educate on condom use for STI protection
    • Offer HPV vaccine if not received
    • Offer STI screening: GC/Chlamydia, HIV

    Education:

    • Discuss expected changes with COCP (lighter, more regular periods)
    • Discuss adherence importance: same time daily
    • Common side effects: nausea, breast tenderness, spotting
    • Risk/benefit: COCP decreases ovarian/endometrial cancer risk but increases risk of

    DVT in smokers or those with risk factors
    • Reinforce safe sex practices and routine STI testing
    • Encourage follow-up in 3 months for contraceptive tolerance and cycle regularity

    Referrals:

    • None needed at this time unless abnormal labs

    Follow-up:

    • Return in 3 months or sooner if side effects present themselves
    • Annual physical exam and STI testing per guidelines

    **## Week1DBresponse.pdf**

    Denise, a 19-year-old female presents to the clinic for an annual physical exam. She is
    G0P0, and presents with irregular menses only occurring every 3-4months apart within
    the past 2 years. She is sexually active and only using condoms occasionally. She is not
    on any other birth control methods. She denies any significant medical or surgical health
    history and denies any other current health problems. She has never had a Pap smear or
    any pelvic exam tests before today. Her pregnancy test is negative and her vital signs are
    all WNL.

    SOAP NOTE

    S – Subjective

    CC: "I want birth control and my periods are irregular."

    HPI:
    Denise is a 19-year-old G0P0 female presenting for her annual exam. She reports
    irregular menses occurring every 3–4 months for the past 2 years. She is sexually active
    and occasionally uses condoms. She denies any history of abnormal vaginal discharge,
    pelvic pain, or previous STIs. Denies fatigue, weight gain/loss, or hirsutism.

    Additional questions to ask:

    • When was your last menstrual period (LMP)?
    • Any recent changes in stress, weight, or exercise habits?
    • Any family history of PCOS, thyroid disorders, or reproductive issues?
    • Number of lifetime partners? Current partner status?
    • History of STI testing?
    • Desire for pregnancy in the next year?

    Medical History: Denies chronic illnesses, surgeries, or hospitalizations.

    Social History:

    • Home: Lives with parents.
    • Education: In college.
    • Alcohol/Drugs: Denies drug use, occasional alcohol socially.
    • Smoking: Denies.
    • Sexuality: Heterosexual, sexually active.
    • Contraception: Inconsistent condom use.

    O – Objective

    Vital Signs: WNL
    General: Alert, cooperative
    POCT:

    • Urine pregnancy test (Negative – already obtained)
    • Gonorrhea/Chlamydia NAAT (recommended)
    • TSH if concern for endocrine cause of irregular menses
    • Consider HbA1c or fasting glucose if PCOS suspected

    Pap smear: Not indicated at this time. According to USPSTF and ACOG guidelines,
    cervical cancer screening with Pap smear begins at age 21 regardless of sexual activity.
    She may have the option now if she consents, but it is not mandatory until age 21

    Pelvic exam: May perform if patient consents, especially for STI testing or symptoms

    A – Assessment

    Primary Diagnosis:

    • Irregular menses, likely secondary to an-ovulation (ICD-10: N92.6 – Irregular
    menstruation, unspecified)

    Differential Diagnoses:

    • Polycystic Ovary Syndrome (PCOS) – Consider due to menstrual irregularity and
    adolescent age

    • Hypothyroidism – Should rule out with TSH if symptomatic

    P – Plan

    Pharmacologic:

    • Prescribe Combined Oral Contraceptive Pill (COCP): e.g., Ethinyl estradiol 30
    mcg/norgestimate 0.25 mg PO daily, 28-day pack. 12-month supply, 0 refills

    o Rationale: Effective birth control and cycle regulation
    o Consider patient preference: patch, ring, or progestin-only if COCP contraindicated

    Non-Pharmacologic:

    • Educate on condom use for STI protection
    • Offer HPV vaccine if not received
    • Offer STI screening: GC/Chlamydia, HIV

    Education:

    • Discuss expected changes with COCP (lighter, more regular periods)
    • Discuss adherence importance: same time daily
    • Common side effects: nausea, breast tenderness, spotting
    • Risk/benefit: COCP decreases ovarian/endometrial cancer risk but increases risk of

    DVT in smokers or those with risk factors
    • Reinforce safe sex practices and routine STI testing
    • Encourage follow-up in 3 months for contraceptive tolerance and cycle regularity

    Referrals:

    • None needed at this time unless abnormal labs

    Follow-up:

    • Return in 3 months or sooner if side effects present themselves
    • Annual physical exam and STI testing per guidelines