Episodic/Focused SOAP Note
Pupil’s Title
Institutional Affiliation
Course
Professor’s Title
Date
Episodic/Focused SOAP Note
Affected person Info:
L.R., 35, Feminine, Black
S.
CC (chief grievance): “I need to have a pap test completed.”
HPI: L.R. is a 35 year-old black feminine who presents to the clinic with the need for an annual Pap smear screening and breast mammogram. She missed the earlier examination owing to the restrictions and dangers of the pandemic. She complains of headache though she states it isn’t extreme. The headache has been ongoing for 3 days. The headache has been main to pounding impact and stress round eyes and temples. Related signs embody nausea, vomiting, photophobia, and phonophobia. She experiences the headache after spending the entire day at work on the pc. The exacerbating and relieving elements embody mild in each eyes. She takes Naproxen to make it tolerable however not utterly higher. She charges the severity at 7/10 ache scale.
Present Drugs: Naproxen 375 mg pill BID.
Allergic reactions: No recognized meals or drug allergy symptoms.
PMHx: No main previous sickness or remedy. She has been having annual Pap smear screening previously with no prognosis.
Soc & Substance Hx: The affected person is a librarian with three youngsters. She is single and loves swimming over the weekend. She has been taking alcohol and tobacco. The consumption has elevated to the extent of habit. She denies abusing marijuana, cocaine, different onerous medication or pharmaceuticals. She lives together with her sister and three youngsters aged 10, 7, and 5 years.
Fam Hx: Her sister has cervical most cancers and presently present process remedy. Her mom died of cervical most cancers. Her dad is wholesome and nonetheless alive. The youngsters are wholesome with none main well being situation. She has no grandchildren.
Surgical Hx: No prior surgical procedures.
Psychological Hx: No historical past of psychological sickness resembling despair or anxiousness. No historical past of self-harm or suicidal or homicidal ideation.
Violence Hx: No historical past of violence at residence or work.
Reproductive Hx: Her LMP was 15th September. She had an abortion within the final yr due to well being problems. She is just not utilizing any contraceptives. She practices vaginal intercourse with a number of companions however since her abortion she has had no sexual activity.
ROS:
GENERAL: No weight modifications, physique fever, chills, or fatigue.
HEENT: Eyes: No blindness or visible loss. No listening to downside, congestion, or sore throat.
SKIN: No lesions or itching.
CARDIOVASCULAR: No chest stress, ache, or edema.
RESPIRATORY: No shortness of breath, sputum or cough.
GASTROINTESTINAL: No anorexia, diarrhea, or belly ache.
GENITOURINARY: No being pregnant or burning on urination. LMP 15/9/2021.
NEUROLOGICAL: No headache, ataxia, tingling within the extremities. No modifications in bowel management.
MUSCULOSKELETAL: No muscle ache, stiffness, or be part of ache.
HEMATOLOGIC: No bleeding, or anemia.
LYMPHATICS: No historical past of splenectomy No enlarged nodes. No historical past of splenectomy.
PSYCHIATRIC: No historical past of hysteria or despair.
ENDOCRINOLOGIC: No historical past of warmth intolerance, polyuria, or polydipsia.
REPRODUCTIVE: Historical past of abortion due to well being problems. She has foul smelling vaginal discharge. The discharge is watery, brown, and blended with blood. She is presently not sexually energetic.
ALLERGIES: No historical past of rhinitis, eczema, hives, or bronchial asthma.
O.
Bodily examination: No bodily examination carried out right now of the gynecology go to.
Diagnostic outcomes: The affected person is coming for the gynecology go to. She missed an annual go to after she conceived. Varied exams are wanted to study the danger of gynecology situations. Breast mammogram is required to set up the danger of breast most cancers. A test for HPV is important to study an infection within the reproductive system (Small et al., 2017). The affected person needs to be examined for STI due to the conduct of a number of intercourse companions. A Pap smear test is important to study the danger of cervical most cancers due to the hereditary nature of the situation (Small et al., 2017). Pelvic examination is important to study the danger of reproductive well being within the feminine affected person.
A.
Differential Diagnoses
C53. 9 – Malignant neoplasm of cervix uteri, unspecified
A74. 9 Chlamydia billable/particular
O86. 11 Cervicitis billable/particular
D25.9 Uterine fibroid unspecified
N73. 9 Pelvic inflammatory illness billable/particular
P.
Further diagnostic exams and medical historical past is important to improve the accuracy of the prognosis. The affected person requires further exams to remove the danger of misdiagnosis (Ind, 2021). A referral to the laboratory is important to study the tissues for cancerous components (Morgan et al., 2019). A blood test is important to remove the danger of most cancers. The affected person ought to take some painkillers to relieve the headache (Rastogi & Rome, 2021). Further examination on the top needs to be completed if the headache continues.
I agree with my preceptor in regards to the case examine.
One of many interventions of the situation is to encourage the affected person to keep away from a number of intercourse companions since they’ll improve the danger of reproductive well being problems (Rastogi & Rome, 2021). Observe-up visits are wanted to study the severity of the situation and begin of remedy.
I realized that a complete examination of a affected person’s historical past and chief grievance is important to study a affected person.
Sooner or later, I’ll attempt to collaborate with different professionals to improve the accuracy of the prognosis. I’ll contemplate the cultural background of a affected person to keep away from delicate conversations resembling intercourse and reproductive components with a feminine affected person.
Lack or failure of entry to the well being facility for gynecology visits is likely one of the elements contributing to the deterioration of the situation (Rastogi & Rome, 2021).
References
Ind, T. (2021). Overview of fertility sparing therapies for cervical most cancers. Greatest Observe & Analysis Scientific Obstetrics & Gynaecology.
Morgan, H. Okay., Winkel, A. F., Nguyen, A. T., Carson, S., Ogburn, T., & Woodland, M. B. (2019). Obstetrics and gynecology residents’ views on wellness: findings from a nationwide survey. Obstetrics & Gynecology, 133(three), 552-557.
Rastogi, R., & Rome, E. S. (2021). Adolescent Gynecology within the Workplace Setting. Pediatrics in Assessment, 42(eight), 427-438.
Small Jr, W., Bacon, M. A., Bajaj, A., Chuang, L. T., Fisher, B. J., Harkenrider, M. M., … & Gaffney, D. Okay. (2017). Cervical most cancers: a world well being disaster. Most cancers, 123(13), 2404-2412.
