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Assignment 2: Episodic Visit: Common Gynecologic Health Conditions Focused Note

Assignment 2: Episodic Visit: Common Gynecologic Health Conditions Focused Note

For this Focused Note Assignment, you will select a patient with common gynecologic health conditions from your clinical experience and construct a patient history, assess and diagnose the patient’s health condition(s), and justify the best treatment option(s) for the patient.

To prepare:

  • Use the Focused SOAP Note Template found in this week’s Learning Resources to complete this Assignment.
  • Select a patient with common gynecologic health conditions whom you examined during the last three weeks in your practicum experience. With this patient in mind, address the following in your Focused Note Template:

Assignment:

  • Subjective: What details did the patient provide regarding her personal and medical history?
  • Objective: What observations did you make during the physical assessment?
  • Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
  • Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
  • Reflection notes: What would you do differently in a similar patient evaluation?

Episodic/Focused SOAP Note Template 

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.”

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.

PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.

Soc & Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.

Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx: Prior surgical procedures.

Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical).

Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (yes or no), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), and any sexual concerns.

ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. LMP: MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:).

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

P

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?

Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).

References

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

Expert Answer and Explanation

Endometriosis Focused SOAP Note

Patient Information:

Ms. Mika, a 34-years-old, female of Caucasian origin.

S.

CC: “Pelvic pain for last four days.”

HPI: Ms. Mika, a 34-years-old female of Caucasian origin working as a saleswoman in one of the local companies came to my office this morning complaining of pelvic pain for the last four days. She notes that the pain radiates from the lower back. Associated signs include painful urination, painful and excessive bleeding during periods, and nausea for two days. She started feeling pain during her last menstrual cycle and often increases when she engages in sex. She has tried OTC ibuprofen but the pain persists. She rates the severity of the pain in 7/10.

Current Medications: OTC ibuprofen.

Allergies: No allergies.

PMHx: No history of major health problems. Received Covid-19 vaccine on January.

Soc & Substance Hx: Denies drugs, alcohol, and tobacco use.

Fam Hx: Father has hypertension, type two diabetes, and HIV/AIDs. Mother died from heart attack. No children

Surgical Hx: Two cervical procedures.

Mental Hx: No history of mental illness.

Violence Hx: No history of violence.

Reproductive Hx: Positive for heavy menstrual bleeding.

ROS:

GENERAL: Positive for nausea, tiredness, fatigue, and dizziness.

HEENT: Unremarkable

CARDIOVASCULAR: No chest pressure or pain.

RESPIRATORY: No cough, sputum, difficulty breathing, or shortness of breath.

GASTROINTESTINAL: Reports nausea.

GENITOURINARY: Reports pain during urination.

NEUROLOGICAL: Reports dizziness.

MUSCULOSKELETAL: Reports pelvic pain.

O.

Physical exam:

Vitals: BP 116/87, HR 67, T36.8, Ht. 5’5’’, Wt. 140lbs, RR 17.

General: The patient is well groomed and looked distressed and is O*3.

Cardiovascular: No gallops. Regular heart rate and rhythm.

Regular rhythm and heart rate (78beats/min), capillary refill <3 seconds, no gallops.

Respiratory: No chest cracks, lungs clear.

Genitourinary: Responds well to temperature extremes

Pelvic: cysts to palpation.

Diagnostic results:

  1. Laparoscopy: Pending
  2. Pap smear: Pending
  3. Pregnancy test: Negative

A.

Differential Diagnoses

Primary Diagnosis

  1. Endometriosis:

Secondary Diagnosis

  1. Uterine Malformation
  2. Pelvic Adhesions
  3. Serositis
  4. Neoplastic Ovarian Cyst

Endometriosis is the primary diagnosis. The symptoms of the disease include painful periods, painful sexual intercourse, excessive bleeding, and pelvic pain (Rolla, 2019). The patient reports all these symptoms, making the disease a primary diagnosis. The diagnosis is also confirmed by cyst in the patient’s pelvic region (Soliman et al., 2017). One of the risk factors of endometriosis is never giving birth (Rogers et al., 2017). The patient has never given birth.

Treatment

The patient can be prescribed a combination of alpha lipoic acid, N-acetyl cysteine, and bromelain for pain management (Lete et al., 2018).

Health Promotion

She can be urged to exercise regularly to avoid weight gain (Lete et al., 2018).

Follow-Up

The patient should come for check-up after six months and if the medication has worked, surgery will be recommended.

Reflection

I have learned that endometriosis treatment should focus on pain management. there is no medication to reduce the growth. I have also learned that follow-up treatment is vital because it can provide healthcare professionals with a chance to evaluate the initial treatment and make changes if necessary (Cardoso et al., 2020). I have also learned that diagnosis of endometriosis be made best after lab tests because the disease highly mimics other conditions. If I was to be assigned the case again, I would have recommended MRI.

References

Cardoso, C. R., Salles, G. C., & Salles, G. F. (2020). Prognostic importance of on-treatment clinic and ambulatory blood pressures in resistant hypertension: a cohort study. Hypertension, 75(5), 1184-1194. https://doi.org/10.1161/HYPERTENSIONAHA.120.14782

Lete, I., Mendoza, N., de la Viuda, E., & Carmona, F. (2018). Effectiveness of an antioxidant preparation with N-acetyl cysteine, alpha lipoic acid and bromelain in the treatment of endometriosis-associated pelvic pain: LEAP study. European Journal of Obstetrics & Gynecology and Reproductive Biology228, 221-224. https://doi.org/10.1016/j.ejogrb.2018.07.002

Rogers, P. A., Adamson, G. D., Al-Jefout, M., Becker, C. M., D’Hooghe, T. M., Dunselman, G. A., Fazleabas, A., Giudice, L. C., Horne, A. W., Hull, M. L., Hummelshoj, L., Missmer, S. A., Montgomery, G. W., Stratton, P., Taylor, R. N., Rombauts, L., Saunders, P. T., Vincent, K., Zondervan, K. T., & WES/WERF Consortium for Research Priorities in Endometriosis (2017). Research Priorities for Endometriosis. Reproductive sciences (Thousand Oaks, Calif.), 24(2), 202–226. https://doi.org/10.1177/1933719116654991

Rolla E. (2019). Endometriosis: advances and controversies in classification, pathogenesis, diagnosis, and treatment. F1000Research, 8, F1000 Faculty Rev-529. https://doi.org/10.12688/f1000research.14817.1

Soliman, A. M., Coyne, K. S., Gries, K. S., Castelli-Haley, J., Snabes, M. C., & Surrey, E. S. (2017). The effect of endometriosis symptoms on absenteeism and presenteeism in the workplace and at home. Journal of Managed Care & Specialty Pharmacy23(7), 745-754. https://www.jmcp.org/doi/abs/10.18553/jmcp.2017.23.7.745

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