Harvard University Patient Complained of Constant Pelvic Pain Case Study

The goals of this assignment are:

1. To utilize nursing theories and research to formulate a management plan
2. To use critical thinking skills in SOAP note writing for all decision making documented throughout SOAP note.
3. To include health promotion and colleague referrals in management plan of SOAP note.

1. Formulate a case for a patient that presents to your office for care. You will write a note for a CPE – Complete Physical Exam( look for format )

• They must have one acute problem ( UTI ) and two chronic conditions.
• Write up a comprehensive note for your patient encounter. Use your template as you learned in class. Be complete based on the age and acuity of this patient.
• In Assessment, write all your diagnoses and ICD-10 codes (you may list differentials)
• After your PE, write up which diagnostic testing and lab work you will order and why?
  • Provide presumptive diagnostic test results for the tests you ordered.
• Write up what treatment and plan (patient education) you will provide and why? Please be specific!
• When do you want to follow-up and why?

One chronic condition to be low level ( HTN ) and the other must be a high-level acuity ( Diabetes )

1. Write up a synopsis of each of the three conditions that this patient has (1 acute and 2 chronic) – 1 page for each

• Incidence and Prevalence of the conditions
• Pathophysiology
• Signs and Symptoms
• How is it commonly diagnosed?
• How is it commonly treated?

1. How do these three conditions affect the patient’s lifestyle? We’ve learned that most diseases in Modern Society are based in lifestyle choices. In just a short paragraph, tie the three diseases together to let me know you understand how they interact and/or what etiology they may have in common.
2. This paper should be maximum 6-7 pages so be very concise about what information you include. Part of this assignment is learning what is important and what is not. Please DO NOT repeat yourself. An excessively long paper will be penalized. Cover page and page of references are not in this page count.
3. APA style matters! This paper should be fully cited with book, journal and website references. Web based references should only be .org, .gov and .edu websites. Old references should be avoided unless there is no new research on the topic (highly unlikely) or if it is a landmark study