Comprehensive Women’s Health History and Physical SOAP Note

Comprehensive Women’s Health History and Physical SOAP Note

Patient Initials: MP              Gender: Female         Age: 41           Race/Ethnicity: Black

SubjectiveReason for Seeking Health Care: “My period keeps getting heavier and longer.”

History of Present Illness (HPI): MP, a 41-year-old black female presented with complaints about heavy and prolonged menstrual flow. The patient also reported pelvic pain at the left side during periods. She described the pain as very severe, especially during the first day of her period.  The pain lasts for the first four days of periods, but she can bleed even for 10 days. the pelvic pain irradiates to the back. She reported that she noted heavy and prolonged periods five months ago because before she used to have normal menstrual that would last only three days. She describes the pain as stabbing that is relieved by heating using a pad and using strong painkillers. No aggravating factors were noted. The pain can be debilitating. She stated that the prolonged, painful, and heavy menstrual flow were beginning to stress her.

Allergies: Denies any food, environment, or medication allergy.

Current Perception of Health: MP feels that sometimes the pain and prolonged and heavier menstrual flow are debilitating. She is however positive that seeking healthcare will provide treatment and relief to the health problem. Nonetheless, she is overly worried that the prolonged and heavy periods are affecting her quality of life and affecting her emotionally.

Current Medications 

Current Medications: Ibuprofen 600mg as needed for the pain.

Menstrual History

Age at Menarche: 13 years

Last menstrual period: 29^th September 2021

Menstrual Pattern: Irregular

Cycle Length: 25-28 days

Duration of Flow: 10 days

Amount of Flow: Heavy

Bleeding Pattern: N/A

Breakthrough Bleeding: None

Gynecologic History

MP is married and sexually active. Denies history of STIs. Had a cesarean section 7 years ago. Does not have a history of infertility. The mother used Diethylstilbestrol (DES) during all her pregnancies to prevent miscarriage. No history of breast disease. The most recent pap smear was on 25^th January 2018. No history of abnormal pap smear findings.

Pre-menopause/menopause

No premenopausal or menopausal symptoms

Sexual and Contraceptive History

Uses intrauterine device (IUD) as the method of contraception. She is sexually active. Monogamous. Does not use condoms. No history of sexual abuse or STIs.

Obstetric History (including complications)

Two births through cesarean section due to prolonged labor for the first time and a repeat cesarean for the second time.

Past Medical History (PMH)

Major/Chronic Illnesses: No history

Trauma/Injury: No history of major trauma or injury

Hospitalizations: Two times during cesarean section

Past Surgical History

Cesarean section (2 times)

Family Medical History

Mother has a history of hypertension. Father has asthma. Maternal grandfather succumbed to a heart attack. Maternal grandmother succumbed to diabetes. Maternal aunt has a history of fibroids.

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Social History

MP was born and raised in Texas, USA. She grew up with both parents and three siblings. Both parents were teachers. MP did not have any developmental issues. She has a degree in BSc. Nursing. She is a practicing nurse. MP is married and lives with her husband and two daughters. She reports that her marriage is the best thing that happened to her. The husband is a successful businessman. They own a home in a leafy suburb. She has a medical insurance cover. She does not smoke or take drugs. However, she takes alcohol occasionally, especially on weekends. Apart from her husband who is her major support, her three sisters and cousins are major support in her life. She is a Christian.

Health Maintenance

She takes a healthy diet (plenty of fruits and vegetables). She is physically active and jogs for 45 minutes every day. Both tetanus and pneumonia vaccines are up to date. The last pap smear was on 25^th January 2018. She attends an annual comprehensive evaluation annually.

Review of Systems (ROS)

General: Denies any changes in weight in the last six months. Denies fatigue or weakness. No distress or exercise intolerance.

Dermatology: Denies any skin breakout or any other issue.

HEENT: Denies any headache, ear pain, hearing loss, eye problem, vision problems, nose congestion, or pain when swallowing.

Neck: No neck pain

Pulmonary System: Denies cough, breath shortness, wheezing, or any distress

Cardiovascular System (CVS): Denies high heart rate, chest pain, or palpitations

Breast: Denies breast pain, nipple discharge, or any changes in the breast

Gastrointestinal (GI) System: Denies any diarrhea, vomiting, abdominal pain, or nausea

Genitourinary (GU) System: Denies any change in nature of urine; reports dysuria and urinary urgency. Denies hematuria. Reports heavy and prolonged vaginal bleed.

Female Genitalia: Denies any problem with genitals

Musculoskeletal System: Denies joint stiffness, gout, joint pain, muscle pain, history of gout, joint stiffness, or cramps.

Neurological System: Denies history of seizures, headaches, syncope, or headaches. Denies tingling, tremors, or tics. Denies any coordination problems or involuntary movements.

Psychologic: Reports stress and anxiety with heavy and prolonged periods. Denies any sleep disturbances. No history of a mental health problem.

Hematologic/Lymphatic: Denies any bleeding or easy bruising. No history of blood transfusion. Reports anemia diagnosis one month ago.

Endocrine: Denies cold or heat intolerance. Denies excessive thirst, excessive sweating, or polyuria. Denies thyroid disease or diabetes.

 

Objective

Physical Examination

Vital Signs

Blood Pressure (BP): 110/77 Hg        Temperature: 36.2⁰C  Heart Rate (HR): 71    Respiratory Rate (RR): 17

Height: 5’5’     Weight : 142 lbs           Body Mass Index (BMI): 23.6            Pain: 0/10

 

General Appearance: The patient is well-groomed and is well oriented to time, place, person, and event. No acute distress. Answers all questions appropriately.

Dermatology: Skin appears normal. Hydrated, no rashes or lesions. The skin is warm, moist, and intact.

HEENT: Head atraumatic and normocephalic. Ear canals patent and TMS pearly grew. Nose, edematous nasal mucosa. Clear rhinorrhea. Eyes, normal conjunctiva. Symmetric, equal, and round pupils.

Neck: Neck moves without resistance. No neck stiffness. No cervical lymphadenopathy.

Pulmonary System: Symmetric chest wall. Lungs clear on auscultation. No wheezes. No rubs. Equal breath sounds.

Cardiovascular System (CVS):  No murmurs, gallop, or rubs on auscultation. Normal heart rate and rhythm in S1, S2. Capillary refill less than 2 seconds.

Breast: No masses or tenderness in breasts. No discharge from the nipple. No skin discoloration. No axillary nodes.

Gastrointestinal (GI) System: Soft and non-tender abdomen. Normal BS in the four quadrants. No mass or hepatosplenomegaly.

Genitourinary (GU) System: Non-distended bladder. No CVA tenderness.

Female Genitalia: Normally developed vagina. No vaginal discharge. No perianal or perineal abnormalities. Vaginal walls bleeding. Enlarged, irregular, mobile, palpable, and tender mass in the uterus contour.

Musculoskeletal System: No muscular atrophy. Steady gait. Full range of movement in all four extremities. No joint stiffness. Lumbar and thoracic spine normal.

Neurological System: Clear speech. Normal gait. Balance stable. Reflexes 2+ bilaterally.

Psychologic: No apparent distress. Alert and well-oriented. Normal speech. Answers questions suitably.

Hematologic/Lymphatic: Vaginal wall bleeding.

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Significant Data/Contributing Dx/Labs/Misc The vaginal walls bleeding and the enlarged, irregular, mobile, palpable, and tender mass in the uterus contour indicates a growth in the uterine. The heavy and prolonged periods.

 

 

Assessment

Differential Diagnoses

Uterine fibroids: Uterine fibroids normally cause pelvic pain, urinary symptoms, and abnormal heavy and prolonged periods (De La Cruz & Buchanan, 2017). The diagnosis is also based on physical examination and clinical presentation.

Uterine rupture: This is a spontaneous tear of the uterus and it may be characterized by vagina bleeding (Badeghiesh et al., 2020). However, the patient reports that she has had heavy and prolonged bleeding during her menses, and this rules out the diagnosis of uterine rupture.

Uterine sarcomas: This refers to malignant cancers that develop from the uterine corpus. Symptoms of uterine sarcomas include pelvic pain, pelvic mass, and abnormal uterine bleeding. (Kommoss et al., 2020). However, the patient reported bleeding during her periods, and thus the diagnosis of uterine sarcomas is ruled out.

Primary Diagnoses

Uterine fibroids

 

Plan

Diagnoses

Uterine fibroids

Laboratory/Diagnostic Studies

• Complete Blood Count
• Vaginal culture,
• Transvaginal pelvic ultrasound

Therapeutic (Non-pharmacological interventions)

N/A

Pharmacological Therapy

• Megestrol acetate 40 mg daily for 14 days (Badran et al., 2020)
• Mifepristone 25 mg for 3 months
• Tylenol 500 mg as required for pain

Patient Education/Anticipatory Guidance

The patient will be advised to maintain general hygiene and ensure physical activities and a healthy diet that is high in fiber, fruits, and vegetables. She will be advised to stop or minimize alcohol intake as alcohol is a known trigger for fibroids (Takala et al., 2020).

The importance of cervical cancer screening annually will be emphasized to the patient.

Referrals

Gynecologist

Oncologist

Follow up

The patient will be reviewed after 2 weeks and also for the interpretation of the laboratory test results.

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Patient Name: (Initials)______________________________        Age ___________

Date: _______________

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References

Badeghiesh, A., Gil, Y., Suarthana, E., Mansour, F., Volodarsky-Perel, A., & Tulandi, T. (2020). The trend of Uterine Rupture and Different Approaches to Myomectomy [35B]. Obstetrics & Gynecology, 135, 28S.

Badran, S. A., Fayyaz, S., Taj, B., & Choudhary, M. I. (2020). Megestrol acetate induced proliferation and differentiation of osteoblastic MC3T3-E1 cells: A drug repurposing approach. Steroids, 157, 108607.

De La Cruz, M. S. D., & Buchanan, E. M. (2017). Uterine fibroids: diagnosis and treatment. American family physician, 95(2), 100-107.

Kommoss, F. K., Chang, K. T., Stichel, D., Banito, A., Jones, D. T., Heilig, C. E., … & Koelsche, C. (2020). Endometrial stromal sarcomas with BCOR‐rearrangement harbor MDM2 amplification. The Journal of Pathology: Clinical Research, 6(3), 178-184.

Takala, H., Yang, Q., El Razek, A. M. A., Ali, M., & Al-Hendy, A. (2020). Alcohol consumption and risk of uterine fibroids. Current molecular medicine, 20(4), 247-258.

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SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive SOAP note is to be written using the attached template below.
Comprehensive Women’s H & P Template.docx Download Comprehensive Women’s H & P Template.docx
For all the SOAP note assignments, you will write a GYNECOLOGICAL SOAP note about one of your patients and use the following acronym:
S = Subjective data: Patient’s Chief Complaint (CC).
O = Objective data: Including client behavior, physical assessment, vital signs, and meds.
A = Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.
P = Plan: Treatment, diagnostic testing, and follow up
Mrs. MP, a 41-years old black female who lives in a single house with her husband and three children who works as a secretary in a law firm, came to the Women’s Health clinic with a chief complaint of, “My period keeps getting heavier and longer.”

Submission Instructions:
• Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
• The references should be formatted and cited in current APA style with support from at least at least 5 academic sources no older than 5 years (2016-2021).
• THE SOAP NOTES MUST BE COMPLETED USING THE TEMPLATE PROVIDED.
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