Nurs 6551: Primary Care of Women – Sample SOAP Note
SOAP Note Week 3
Date: xxxx
Name: TS Age: 33 Gender: Female Race: Caucasian
SUBJECTIVE
Chief Complaint: TS came to the clinic with complains of unusual bleeding and discharge, difficulty urinating, pain around vaginal area, pain during intercourse and abnormal pap results. Nurs 6551: Primary Care of Women – Sample SOAP Note.
HPI: The patient presented with painful urination, vaginal discharge and coitus pain. She also noted an increase in vaginal bleeding, Pap tests taken have been abnormal and pelvic area has also been experiencing pain. This has been going on for two weeks, for which she has been using OTC Ibuprofen.
PMH:
Allergies: None
Current Medication: Ibuprofen 600mg BD.
Immunization: Up to date
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Previous Routine Tests: A normal pap smear 6 months ago
Past Illnesses: Recurrent UTI.
Hospitalizations: None.
Pregnancy History: G0 P0 A0
Family History: Mother has Type 2 Diabetes, Father has Hypertension, No siblings; She lives with husband who has Arthritis. Nurs 6551: Primary Care of Women – Sample SOAP Note.
Social History: She is an occasional smoker and is a social drinker. She denies use of illicit drugs. She tries to stay active by doing Zumba dance during free times. She works as a Lyricist for a music company.
ROS:
Constitutional: The patient appears unwell and is worried that the symptoms are gradually increasing and it has even started to affect his day to day life because of the pain. She denies incidences of fever, diarrhea, nausea and weight gain or loss. Nurs 6551: Primary Care of Women – Sample SOAP Note.
HEENT: No headache, head bruises or rashes. Hearing capability seems normal. Uses reading glasses.
Cardiovascular: Normal heart rate and denies any murmurs, gallops and clicks.
Respiratory: The chest rises and falls rhythmically with the patient not complaining of wheezing, and coughing.
Gastrointestinal: Denies diarrhea, abnormal bowel movements and pain in the abdomen.
Genitourinary: Complains of pain while urinating, painful coitus, pain in the pelvic area, vaginal discharge and abnormal bleeding. Patient denies hematuria, urgency and frequency in urination. Nurs 6551: Primary Care of Women – Sample SOAP Note.
Musculoskeletal: The patient denies any pain in the muscles, back pain or pain in the joints.
Neurologic: The patient has no deformities with the balance and is sensitive to the stimuli.
Psychiatric: Denies insomnia, nightmares, suicidal thoughts and abnormal headache.
OBJECTIVE:
Constitutional: T 97.5F, BP 114/71, HR 77, RR 23, Ht 4” 5’, Wt 146lbs
General: The patient is well groomed and responds questions. She looks distressed.
Head: No deformities or poor hair growth observed.
Eyes: Sclera white, normal light sensitivity and no abnormal discharge, no redness
Ears: Bilaterally intact, TM intact, no discharge
Nose: Pink and Moist mucosa, no sneezing or excessive discharge or congestion, no polyps
Throat: No Inflammation, swelling or dislocation. Nurs 6551: Primary Care of Women – Sample SOAP Note.
Mouth: Oral mucosa is pink and moist
Cardiovascular: RRR, no murmurs, clicks or gallops. S1 and S2 present, capillary refill <3 seconds.
Respiratory: Chest clear, no wheezing or rales
Gastrointestinal: No diarrhea or constipation; generalized tenderness; bowel sounds present in all 4 quadrants.
Genitourinary: Painful urination, painful coitus, pain in the pelvic area, vaginal discharge and abnormal bleeding, no hematuria, urgency and frequency in urination. Nurs 6551: Primary Care of Women – Sample SOAP Note.
Musculoskeletal: Normal gait, no muscular tenderness or swelling
Neurologic: The patient has normal gait, responds effectively to all temperature extremes.
Psychiatric: No insomnia, nightmares, suicidal thoughts. Nurs 6551: Primary Care of Women – Sample SOAP Note.
Labs: Pap smear, endometrial biopsy, Curettage and dilation, transvaginal ultrasound and Computed tomography.
ASSESSMENT
Diagnosis: Endometrial cancer
Endometrial cancer: This refers to a type of cancer that majorly affects the uterine lining makes the cells to grow abnormally to the point where they can affect other body parts (Shafer & Van Le, 2013). During early onset of the condition, there will be excessive vaginal bleeding that does not have a relationship with menstrual periods. The other symptoms include painful sex, pain while urinating, vaginal discharge and painful pelvic area (Kulkarni & Harshavardhan, 2017). The Pap smear showed abnormal results of glandular cells that are abnormal. All the other tests were positive for endometrial cancer. Nurs 6551: Primary Care of Women – Sample SOAP Note.
Endometrial Hyperplasia: Common presentation is abnormal uterine bleeding. In premenopausal women, the symptoms include irregular heavy menstruation or amenorrhea in some cases. Endometrial biopsy differentiates endometrial hyperplasia from cancer. However there in 42.6% cases of endometrial cancer, the initial diagnosis was hyperlasia with atapia (Endometrial Cancer, 2018). Nurs 6551: Primary Care of Women – Sample SOAP Note.
Endometriosis: Symptoms include pain, dyspareunia and painful defecation. It is common in young premenopausal women. Physical examination reveals tenderness and nodularity. Pelvic ultrasound can be done to confirm endometrioma (Endometrial Cancer, 2018).
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PLAN:
The ideal treatment for this cancer is through surgery where the tumor will be removed (Shafer & Van Le, 2013). Additionally, some of the healthy tissues that surround the tumor will be removed since they could be containing some cancer cells. Simple Hysterectomy will be ideal for the patient due to the extent of the spread of the cells (Eifel, 2015). In this case, the cervix and uterus will be removed since the cancer cells have not spread so much to the other parts of the reproductive system. Nurs 6551: Primary Care of Women – Sample SOAP Note.
The patient will have to keep visiting the health facility after the procedure for routine maintenance and test to ascertain that the tumor does not regenerate. Nurs 6551: Primary Care of Women – Sample SOAP Note.
Reflection notes:
In this case, the diagnosis itself is a big shock to the patient. Also, the pain suffered by TS is limiting her from his daily activities. Ignoring these could attribute to mood disorders or depression. She should be introduced to support groups with people going through the same diagnosis. This will also help her overcome the mental and physical pain caused by the disease. Nurs 6551: Primary Care of Women – Sample SOAP Note.
References
Eifel, P. J. (2015). Treatment of Endometrial Cancer. Pelvic Cancer Surgery, 315-325. doi:10.1007/978-1-4471-4258-4_30
Endometrial cancer. (n.d.). Retrieved March 18, 2018, from https://online.epocrates.com/diseases/26635/Endometrial-cancer/Differential-Diagnosis
Kulkarni, Y., & Harshavardhan. (2017). Recurrent Endometrial Cancer. Current Concepts in Endometrial Cancer, 107-116. doi:10.1007/978-981-10-3108-3_9. Nurs 6551: Primary Care of Women – Sample SOAP Note.
Shafer, A., & Van Le, L. (2013). Endometrial Hyperplasia and Endometrial Cancer. Gynecological Cancer Management, 53-66. doi:10.1002/9781444307542.ch5 . sampleSOAPnote . Nurs 6551: Primary Care of Women – Sample SOAP Note