Topic: Menorrhagia on a 18 y/o female patient.
CC: I have been having heavy periods for the past 3 months lasting 10 to 11 days with constant pain in the pelvis area.
Subjective Information: “CC”, HPI :OPQRST IF f/u: health status since the last visit, response to therapies. PMH, PSH, FH, ROS complete.
Objective Information: Complete physical exam with critical elements related to subjective data.
Assessment: Minimum of 3 differentials supported by S + O data Final diagnosis noted, and optimal and thorough subjective and objective assessment is presented for final diagnosis.
Plan: Diagnostic tests/therapies/follow-up, Patient education, health promotion. Medications listed with dosage/SE/Education/
Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence-based reasoning & literature in designing the plan of care, compare to the plan of care implemented.