Week 7 Soap Note .

Posted: November 29th, 2022

Week 7 Soap Note .

Reflect on a patient who presented with a breast condition during your Practicum Experience. Describe the patient’s personal and medical history, drug therapy and treatments, and follow-up care. Then, explain your patient education strategies for patients with or at risk of breast conditions. Include a description of how you might teach patients to perform breast self-examinations.Week 7 Soap Note .

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SUBJECTIVE DATA:
Patient Initials: __ET___ Age: _32__ Gender: _¬¬¬¬F__
Chief Complaint (CC): “I have irregular menstruation”
History of Present Illness (HPI):A Caucasian obese female presented with complaints of irregular menstruation and lower pelvic pain for the past two years. ET reported that she had noticed she was gaining weight, particularly around the waist, and increased hair growth on her body. She further stated that her menstrual cycle was regular but for the past two years it has become irregular and skips 3-4 prior to the subsequent menstrual cycle. The patient reported her desire to get pregnant without success. She further reported that in spite of monitoring her ovulation, it was clear she had not ovulated for the past six months since she started using the ovulation kit. The patient denied amenorrhea or dysmenorrhea or fever. She is very sad due to her inability to conceive.
Location: Pelvis, and lower abdominal
Duration: Two years
Quality: Pelvic and lower abdominal pain; hair growth
Radiation: None
Severity: 8/10 on the pain scale
Timing/Onset: Two years ago.
Alleviating Factors: Painkillers medications
Aggravating Factors: None
Relieving Factors: Ibuprofen as the pain reliever and a heating pad
Treatments/Therapies: Ibuprofen, pain reliever and a heating pad
Medications:Ibuprofen
Allergies:None
Past Medical History (PMH):None
Past Surgical History (PSH):None
OB/GYN History:Age at menarche 13-years;LMP 09/09/2012; cycle: 6 days, irregular & very painful cramping.
Contraception:No birth control measures
Cervical and vaginal cytology:
Last Pap smear 8/08/2019: Negative
Infections:No history of sexually transmitted infections, PID or vaginitis
Fertility/infertility:N/A
Sexual History
1. Sexually active and heterosexual with one partner
2. No history of sexual abuse
Obstetric history:
• Para: 0
• Gravida: 0

Personal/Social History:Married; university graduate; a teacher by profession; lives with one daughter and the husband; does not use also alcohol abuse or illicit drugs.Week 7 Soap Note .
Health Maintenance:The patient takes vitamin D supplements; Vegetarian; Physically active; Last Pap smear 8/08/2019: Negative
Immunizations History:Flu vaccine 10/10/19; Pneumococcal vaccine 08/08/19
Significant Family History:Father: Diabetes and hypertension; Mother: Diabetes and cervical cancer.

Review of Symptoms:
General: Increased weight; no fever, no fatigue, no weakness.
Head: Denied migraine or headache.
Eyes: No visual problem
Chest: No chest pain, no cough
Heart: No palpitation, normal pulse rate
Breast: No lump; no nipple discharge; admitted breast pain
Cardiovascular: Denies any chest pain; no murmurs, no palpitations
Respiratory: No exposure to tobacco smoke, no wheezing, or cough
Gastrointestinal: Increased waistline; central obesity; lower abdominal pain.
Urinary: No urinary tract infection
GYN: Pelvic pain present; irregular periods; no ovulation; difficulties in getting pregnant; no vaginal discharge or bleeding
Musculoskeletal: No muscle or joint pain.
Skin: Hair growth on the skin; uses a sunscreen with sun exposure
Psychiatry: No mental health problems, denies sleep disturbances
Neurological: denieddizziness, weakness, or seizures.
Endocrine: No diabetes; no thyroid problem
Immunologic: No recurrent infections or immune deficiencies.
Hematologic: Normal Hb level, no unusual bleeding; no history of blood transfusion
Allergic/Immunologic:No allergies; no recurrent infections.Week 7 Soap Note .

OBJECTIVE DATA:
Physical Exam:
General: The patient is overweight, alert/oriented, dressed appropriately and answers questions suitably.
Vital signs: T 36.8, B/P 125/76; SPO2 100% RA; RR 17; P 68; Weight 105 kgs, BMI 30.3, Height 5ft 5in.
HEAD: Scaly scalp
Neck: Excess skin fold, no thyromegaly.
Chest/Lungs: Increasedhair on thechest; normal breathing rate
Heart: Normal rate and rhythm.
Abdomen/pelvic: lower abdominal tenderness, enlarged multiple ovaries, waist circumference >35;
Back: Increased hair on the upper back.
Skin: Coarse hair on the skin
Breast: + pain; no discharge or swelling
Genitals: Normal external genitals; enlarged clitoris; cervix closed; no rash or discharge.

Lab/Diagnostic Tests and Results:
• Pregnancy urine test for HCG): negative
• Testosterone/androgen test: high/abnormal
• Prolactin test: level high/abnormal, + infertility
• TSH test: normal ruled out a thyroid problem
• Luteinizing hormone concentration/follicle–stimulating level test: Elevated
• Vaginal ultrasound: Thickening endometrium lining; + multiple cysts in the ovaries (Blackshaw et al., 2019).Week 7 Soap Note .

ASSESSMENT:
Differential Diagnosis (DDx):
1. Polycystic ovarian syndrome
2. Pregnancy
3. Endometritis
Final Diagnosis:Polycystic ovarian syndrome

PLAN:
Treatment / Management Plan and Follow up Care
After the diagnostic and laboratory tests, polycystic ovarian syndrome was confirmed as the diagnosis. The treatment/management plan will focus on improving fertility and reducing symptoms of hyperandrogenism (Hayek et al., 2016). However, it is necessary to implement long-term measures to restore regular menses. Since the patient is overweight, the safest measure for restoring ovulation is weight loss. The patient will be prescribed a calorie-restricted diet that limits carbohydrates and fats, increased intake of vegetables and fruits, and regular exercising (Mani et al, 2018).Week 7 Soap Note .
Medications:
• Motrin 200-400 mg orally as required for pain
• Metformin 500 mg to restore ovulation, reduce body mass, and lower the growth of abnormal hair
• Clomid 50 mg orally: This will treat the ovulatory dysfunction by stimulating ovulation and treating the infertility
• The patient will be reassessed after 3-6 months in order to assess the progress and adjust the therapy accordingly.

Nonpharmacological Treatment
The patient will be advised to start using a heating pad as required for pain. The patient will also be advised to exercise regularly and consume a diet rich in fruits and vegetables and low in fats and carbohydrates in order to help in weight reduction and also improve ovulation abnormalities allied to polycystic ovarian syndrome (Kataoka et al., 2017).Week 7 Soap Note .

Health Promotion
The patient will be given educational materials on polycystic ovarian syndrome, including the causes, risk factors, and management therapy. The patient will be educated regarding the importance of proper nutrition & exercise. The patient will be advised to integrate regular physical activities and exercise as part of her daily routine and consuming vegetables and fruits while cutting down the intake of high-energy foods (Mani et al, 2018). The patient will also be advised to maintain good mental health and to seek help in case she starts developing anxiety and depression due to polycystic ovarian syndrome (Sadeeqa et al., 2018). The patient will be provided with resources to help in weight loss and maintain a healthy lifestyle.
No identifiable need for referral.Week 7 Soap Note .

Reflection:
From this assignment, I learned that polycystic ovarian syndrome, could be the main cause of infertility in women, and the cause is normally sex hormonal imbalance. It was also interesting to learn that male hormone androgens could contribute to the physical changes allied to polycystic ovarian syndrome. It was also enlightening to learn that maintaining health is very important in the management of polycystic ovarian syndrome. The treatment plan was developed in accordance with the desire of the patient to have a baby.Week 7 Soap Note .
SUBJECTIVE DATA:
Patient Initials: _____ Age: _____ Gender: _¬¬¬¬__
Chief Complaint (CC):
History of Present Illness (HPI):
Onset:
Location:
Duration:
Characteristics:
Aggravating factors:
Relieving factors:
Treatments/Therapies:
Severity:
Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

OB/GYN History:
Menstrual History:
1. Age at menarche –
2. LMP-
3. Menstrual Pattern
a. Duration of flow-
b. Amount of flow-
c. Associated pain with menses-
d. Intermenstrual bleeding-
4. Menopause-
Contraception:
5. Current method and satisfaction-
6. Previous methods, complications, and reasons for discontinuation-

Cervical and vaginal cytology:
7. Most recent Pap –
8. History of abnormal pap smears-
Infections:
9. No history of STIs, vaginitis, or PID (if this is true for your patient)
Fertility/infertility:
1.
Sexual History: (example)
10. Heterosexual, mutually monogamous relationship
11. No concerns with libido or orgasm. Has experienced intermittent dyspareunia x 1 month.
12. No history of sexual abuse or assault
13. Denies sexual intercourse in the last 7 days.
Obstetric history: (example)
14. G1P1001
15. Denies maternal, fetal, or neonatal complications
Personal/Social History:Week 7 Soap Note .

Health Maintenance:
(include things such as vitamin supplementation, diet, exercise routine, seatbelt use sunscreen use, firearms in the household, last pap and results, sigmoidoscopy/colonoscopy, bone densitometry, lipid analysis, glucose, or thyroid testing)
Immunizations History:

Significant Family History:
(don’t forget to list any family history of breast, ovarian, or uterine cancer)
Review of Symptoms:
General:
Skin:
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Hematologic:
Endocrine:
Allergic/Immunologic:

OBJECTIVE DATA:
Physical Exam:
Vital Signs

General:
HEENT:
Neck:
Chest:
Lungs:
Heart:
Peripheral Vascular:
Abdomen:
Genital/Rectal:
External Genitalia:
Vulva/Labia Majora:
Bartholin Gland:
Skenes:
Clitoris:
Urethra:
Bladder:
Vagina:
Cervix:
Uterus:
Adnexa:
Rectum:
Musculoskeletal:
Neurological:
Lymph Nodes:
Skin:
Lab/Diagnostic Tests and Results: (example)
16. Urine hCG- negative
17. Pap smear- results pending
18. Vaginal culture- pending
19. Urine STD panel- pending
20. Transvaginal US- pending

ASSESSMENT:
Differential Diagnosis (DDx):
21.
22.
23.
Final Diagnosis:
PLAN:
1.
2.
3.
4. Referrals-
5. Further labwork or diagnostics needed??
6. F/U
7. Health Promotion:
8. Disease Prevention:

Reflection:

Week 7 Soap Note .