SOAP NOTE WEEK

Type: SOAP NOTE

Subject: Midwifery and Women's Health

Subject area: Nursing

Education Level: Masters

Length: 1 pages

Referencing style: APA

Preferred English: US English

Spacing Option: Double

Title: Soap Note Week 4

Instructions: please do a womens care soap note on annual exam for a women with no issues. i have attached the rubric and the template. i need atleast 1 diagnosis and 3 differential diagnosis to go with that diagnosis.

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Also Read: 

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Focus: annual exam healthy women

Soap Note Week 4

Name

Institution

Course

Date

Subjective information

Patient’s Information

Date: 08/06/2021

Initials: Mrs.

Age: 45-year-old

Sex:  Female

Race: Mexican American

Chief Complaint: Annual Women’s Visit

 History of the Present illness

The 45 year old Female visited the hospital for her annual checkup session for external genitals, Pap test and breast cancer screening. The 45-year-old Mexican American alluded that her menstrual cycle occurs after around 28 days. During this period, she experiences 1-2 days of bleeding and so she must use up to 4 tampons daily. She experiences occasional fatigue and bloating. She also noted that, she sometimes feels mild discomfort though it does not last for long and so she feels no need to take ibuprofen. Onset: It happens during her menstrual cycle.

Medical history

Hospitalizations and/or surgery: Cholecystectomy that took place 15 years ago. Main childhood ailments: Patient denies history of measles, pertussis, mumps, scarlet fever, rheumatic fever. Patient states history of asthma since childhood. 

Surgical History

She has had one major surgery done on her. The 45-year-old Mexican American female had to undergo a cesarean section during the delivery of her firstborn. The doctors had decided that vaginal delivery would not be a safer option for her. This was due to the large size of the fetus. She has also had several minor surgeries for instance repair of cut wounds and removal of warts.

Family History

Her father died of throat Cancer age 78, while the mother died after involving in a car accident at age 54.  The 45-year-old Mexican American has a twin sister with no significant medical history. She has four children who are very healthy. The husband is also healthy at 51 years old and takes no medications.

Pertinent Allergies: Penicillin that causes rashes to the skin. Denies food or environmental allergies.

Personal and Social History

Cultural background and practices: The 45-year-old was born in Mexico, moving to USA when she was 25 years old. She is a middle school teacher for many years and states great life satisfaction, mild sources of stress that she considers as motivation for improvement, and states religious catholic believes. Home environment: Patient lives with husband and 3 of her 4 kids, which are all very healthy. No pets. 

Occupation: Full time school teacher for a large middle school. Environment: Patient lives in a single-family home and works full time as a school teacher. Denies community services utilization, recent travels, and other exposure to contagious diseases as far as she is aware. However, she admits the possibility of infection exposure due to her job work with kids that many times show signs of illness with cough and fever during classes.

 

Substance Abuse History

The 45-year-old Mexican American occasionally drinks alcohol with her friends; denies smoking and smoking history; she limits salt intake.

ROS

General symptoms: The 45-year-old Mexican American denies weight loss, night sweats, fever, and momentary loss of consciousness or dizziness.

HEENT: The patient denies unusual headaches, blurred vision, nasal discharge, and epistaxis or hearing loss.

Respiratory: The patients indicated having mild chest pains when she coughs.

Breast: The patient denies having pain or breast development issues.

Heart and blood vessels: Patient states chest pain only during cough attacks during only a few seconds to 1 minute. Episodes seems to be related to activity and present with mild palpitations and dyspnea.

Peripheral vasculature: The patient denies claudication or thrombosis.

Hematologic:  The patient denies history of anemia.

Gastrointestinal: Patient denies appetite changes, digestion issues, intolerance of any foods, dysphagia, or heartburn.

Diet: The patient denies any dietary restrictions.

Endocrine: Patient denies any diabetic history.

Gynecological: Patient denies vaginal discharge/bleeding; or itching; Patient denies infertility history.

Genitourinary: Patient denies dysuria, flank or suprapubic pain.

Musculoskeletal: Patient denies joint stiffness, pain, restriction of motion or swelling.

Neurologic: Patient denies sensory deficits, syncope, faintness, paralysis, paresthesia, or ataxia.

Psychiatric: Patient denies depression, mania, mood changes, or difficulty concentrating.

 

Objective Information

Height: 153cm

Weight: 77kg

BMI: 32.44 kg/m2

Blood pressure: 144/78

Temperature: 37.2

Pulse: 111

Physical Examination

General appearance: The patient has fever and a persistent cough. 

Skin: Skin warm, dry, and intact. No rashes, cyanosis, lesions, or edema noted. The color is uniformity; with texture, temperature, turgor, and hygiene within normal limits.

HEENT, Head: Size and head position within normal limits; Eyes: The patient eyes are sclera white; Ears: No redness noted on pinna or auricle; Nose: The external nose is reddened; Throat/Mouth: Dry oral mucosa with no oropharynx lesions and uvula appears midline but swollen.

Lung: No wheezes.

Breast: Size, contour, symmetry, nipples appearance, venous patterns, and tissue consistency WNL.

Heart: S1S2, no murmurs, regular cardiac rhythm. Patient is sinus tachycardic at range from 102 to 120, confirmed with EKG. No gallops.

Breast: No presence of masses, scars, tenderness, thickening, retractions or dimpling.

Pulmonary: S1S2, no murmurs, regular cardiac rhythm. Patient is sinus tachycardic at range from 102 to 120, confirmed with EKG. No gallops.

Abdomen: Nontender, soft, nondistended, no pulsatile or bruits masses, no organomegaly, active bowel sounds all 4 quadrants and WNL. No visible peristalsis or hernias (Raisler, O'Grady, & Lori, 2003).

Female Genitalia: Appearance of external genitalia, perineum, and distribution of pubic hair WNL. Rugated pink vaginal walls, no lesions, no discharge or blood, strong muscular tone. Squamocolumnar junction identified on exam, 12 cm in diameter. No erythema, discharge, or lesions appreciated on exam.

Uterus –Small, midline, firm, smooth, mobile, non-tender with movement.

Lymphatic System: Presence of lymph nodes in head, neck, submandibular, supraclavicular, infraclavicular, epitrochlear, axillary, or inguinal areas all WNL related to size, shape, warmth, tenderness, mobility, consistency.

Musculoskeletal System: Alignment of extremities and spine as expected; symmetric body parts, muscle mass and tone all WNL.

Neurologic System: Cranial nerves grossly intact. Gait balance, coordination with rapid alternating motions, sensory function (Shorten, 2017).

Psychiatric: No signs of depression, anxiety, disturbance in thought content, or hallucinations.

Extremities: no deformities, ambulates with no weakness bilaterally on inspection, no varicosities, no cyanosis or edema. 

Assessment

Differential diagnosis

Uterine Fibroids, Urinary Incontinence and Pelvic Floor Prolapse.

Main

Menstrual Disorders

Plan

Diagnostic labs

Orders placed for Pap smear screening.

Patient slated for Mammogram.

Treatment

Continue Toprol-XL 50 mg PO daily, Synthroid 125 mcg PO daily as directed by PCP.

Recommended patient consider changing type of birth control to IUDto reduce bleeding during menstrual cycles.

Follow up: 1 month 

Will call patients with laboratory results from Pap smear.

 Reference

Raisler, J., O'Grady, M., & Lori, J. (2003). Clinical teaching and learning in midwifery and 

Women’s health. Journal of midwifery & women's health, 48(6), 398-406.

Shorten, A. (2017). Midwifery and women's health. Evidence-based nursing.

Stewart, E. A., Laughlin-Tommaso, S. K., Catherino, W. H., Lalitkumar, S., Gupta, D., & 

Vollenhoven, B. (2016). Uterine fibroids. Nature reviews Disease primers, 2(1), 1-18.