1).What additional history questions related to L.W.’s reproductive system would be vital to ask next?
2) Document what body system(s) that you would perform in completing a physical examination for L.W., using medical terminology. For example for performing a physical examination on a patient‘s lungs, write “examine the respiratory system.” Do not write what you are looking for or at in that body system, write the system only.
3) List L.W.’s symptoms and problems to this point?
4) What primary care clinic (not hospital-based) labs do you like to order, if any? Options include: Hemoglobin (HGB) Urine Dip testing (UA-Dip) Blood sugar testing Fecal occult blood (FOB) test Microscopic exam for –chlamydia and gonorrhea Urine pregnancy testing Rapid strep testing Urine drug toxicology screening Urine gonorrhea/chlamydia-(Urine GC/CT) testing NO labs
6) ASSESSMENT – Choose the most likely primary medical diagnosis for L.W.?
7) Plan- Treatment, PT, ED, F/U Write a SOAP note for L.W.?
8) From L.W.’s medical diagnosis you selected, develop and document either a concept map or write a brief description of the underlying pathophysiology. Document both the microcellular and macro cellular changes that can occur. Cite your evidence based resource where you obtained your information