Focused Soap Note With Differential Diagnosis Essay

Elaine Goodwin is a 38-year-old G5P5006  presenting to your clinic today to discuss contraceptive options.  She states that she is not interested in having more children but her new partner has never fathered a child. Her medical history is remarkable for exercise-induced asthma, migraines, and IBS. Her surgical history is remarkable only for tonsils as a child. Her social history is negative for alcohol, tobacco, and recreational drugs.  She has no known drug allergies and takes only vitamin C. Hospitalizations were only for childbirth. Family history reveals that her maternal grandmother is alive with dementia, while her maternal grandfather is alive with COPD. Her paternal grandparents are both deceased due to an automobile accident. Her mother is alive with osteopenia and fibromyalgia, and her dad is alive with a history of skin cancer (basal cell). Elaine has one older sister with no medical problems and one younger brother with no reported medical problems.  Focused Soap Note With Differential Diagnosis Essay

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• Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 P 68 
• HEENT:  wnl 
• Neck: supple without adenopathy 
• Lungs/CV: wnl 
• Breast: soft, fibrocystic changes bilaterally, without masses, dimpling or discharge 
• Abd: soft, +BS, no tenderness 
• VVBSU: wnl, except 1st degree cystocele 
• Cervix: firm, smooth, parous, without CMT 
• Uterus: RV, mobile, non-tender, approximately 10 cm, 
• Adnexa: without masses or tenderness  Focused Soap Note With Differential Diagnosis Essay

Please POST your FOCUSED SOAP NOTE with your differential diagnosis. Include the additional questions you would ask the patient. Be sure to include an explanation of the tests you might recommend, ruling out any other issues or concerns and include your rationale. Be specific and provide examples. Use your Learning Resources and/or evidence from the literature to support your explanations. Focused Soap Note With Differential Diagnosis Essay