Assignment 2: Episodic Visit: Common Gynecologic Health Conditions Focused Note Student Name Walden University PRAC - 6552C Advanced Nurse Practice in Reproductive Health Care Practicum Dr. Ortiz Date Assignment 2: Episodic Visit: Common Gynecologic Health Conditions Focused Note Episodic/Focused SOAP Note Patient Information: TS, 57 year-old AA Female S. CC (chief complaint): Brown vaginal discharge for several days last week. HPI: This is a 57-year-old nullipara post-menopausal African American female who reported to the clinic for a one-week history of brown vaginal discharge. She had noticed occasional spotting on her underwear for the past year, but she did not think anything about it. She has a significant family history with her mother passing from “some female cancer,” her sister has breast cancer, and her brother died from colon cancer. She could not conceive, has been up to date with her mammogram and pap smear two years ago, both of which have been negative with a NILM HPV negative, atrophic changes, no endocervical cells. Her colonoscopy result from last year was also negative. Her diabetes is controlled with oral medications. She denies any pain. Current Medications: Metformin 500 mg Oral BID Multi vitamins/OCT Allergies: Medication Allergies: Denies Food Allergies: Denies Seasonal Allergies: Denies Latex allergies, Animal/Pet allergies: Denies PMHx: DM-II on oral medications, well managed. Nullipara, never been able to get pregnant Surgical history none Up to date with mammograms Had a colonoscopy one year ago with a negative result Pap smear two years ago with an NILM HPV negative, atrophic changes, no endocervical cells Up to date with childhood, flu, Tetanus and COVID vaccine. Soc & Substance Hx: TS is a patient care technician, who works the night shift in the medical unit at a local hospital. She does not drink alcohol, does not smoke cigarettes, or do any illegal substance. She is married but no children. She reports using a seatbelt while driving without using cell phones. She also reports having smoke detectors at home. She says that her husband owns a gun which is always locked away. She feels safe at her home and around her neighborhood. Fam Hx: Mother passed away from “some female cancer.” Sister alive with a history of breast cancer Younger brother passed from colon cancer No other family history she remember. Surgical Hx: None Mental Hx: Denies history of anxiety, depression, sleep disorder, suicidal or homicidal ideation Violence Hx: Reports a safe living environment, denies a history of sexual harassment, sexual abuse, or violation. Denies past/present physical or psychological abuse.............Continue