This Note Please Question & Answer Guide (With Explanation)
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Key Explanation
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Original Question
Fix this note, please. In the PE you described the nexplanon and its location. The removal of the nexplanon belongs in the treatment plan. You need to identify your treatment section. You have it written under diagnosis. Dr. Falsett Chief Complaint (CC): Nexplanon Removal and Birth control consult History of Present Illness (HPI): 18-year-old female coming in for Nexplanon removal. She complains of heavy unpredictable bleeding that has not stopped since December 26th 2024. She wants to discuss other birth control options and thinks she would like the copper IUD. She reports one sexual partner in the last year and does not smoke or drink. Medications: • · Nexplanon Allergies: • · NKA Social History: • · Reports one partner in the last year • Denies smoking, alcohol use or illicit drugs. Physical Examination (PE): • Well nourished, in no distress, oriented X3, calm mood and effect, ambulating without difficulty. • Vital Signs: Blood Pressure: 128/64, pulse 81, RR 18, temperature 98.1, 98% 02, W; 163, H; 5’4 · Removed Nexplanon on Left arm- sterile procedure maintained- sterile bandage applied. Testing: · Pregnancy test – negative Diagnosis: · Contraceptive consult · Nexplanon removal · Educated on Incision site maintenance.
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