Episodic/Focused SOAP Note
Pupil’s Title
Institutional Affiliation
Course
Professor’s Title
Date
Episodic/Focused SOAP Note
Affected person Data:
LB, 35, Feminine, African-American
S.
CC (chief criticism): Current for annual gynecology go to, breast mammogram,
HPI: LB is a 35-year outdated African-American feminine who presents for annual gynecology go to, breast mammogram. She missed the earlier examination owing to the restrictions and dangers of the pandemic.
Present Medicines: Aspirin 81mg every day, allergy meds as wanted, Tums as wanted along with her meals by mouth, Melatonin 3mg as wanted by mouth at evening
Allergic reactions: Allergic to adjustments in climate. No drug allergy.
PMHx: No historical past of sickness, admission in hospital, or surgical procedures.
Soc & Substance Hx: No alcohol or tobacco use. No member of the family with breast most cancers or reproductive well being sickness.
Fam Hx: No historical past of sickness within the household. Lives alone however has a boyfriend.
Surgical Hx: No previous surgical procedures.
Psychological Hx: No historical past of analysis with psychological sickness.
Violence Hx: No historical past of violence.
Reproductive Hx: The affected person has no youngsters. She is getting ready to have youngsters within the subsequent yr. Historical past of UTI with out indicators reported or assessed. No being pregnant. No delivery controls used.
ROS:
GENERAL: No unintentional weight reduction or achieve, fever, or fatigue.
HEENT: No visible loss, double imaginative and prescient, listening to loss, congestion, or sore throat.
SKIN: No itching, rashes or lesions.
CARDIOVASCULAR: No chest ache, stress, or discomfort.
RESPIRATORY: No coughing or shortness of breath.
GASTROINTESTINAL: No vomiting, nausea, or diarrhea.
GENITOURINARY: No adjustments in bladder management. Historical past of UTI.
NEUROLOGICAL: No dizziness, headache or irregular bladder management.
MUSCULOSKELETAL: No ache within the muscular tissues, joint, or again.
HEMATOLOGIC: No bleeding or anemia.
LYMPHATICS: No historical past of splenectomy.
PSYCHIATRIC: No historical past of psychological sickness.
ENDOCRINOLOGIC: No head or chilly intolerance.
REPRODUCTIVE: No being pregnant, not sexually energetic, getting ready to have youngsters. No delivery controls tablets used.
ALLERGIES: No historical past of hives or rhinitis.
O.
Bodily examination: No bodily examination carried out.
Diagnostic outcomes: The affected person is coming for the gynecology go to after lacking final years’ annual examination. A battery of exams is required together with a breast mammogram to search for indicators of breast most cancers (Bowden et al., 2021). She additionally wants Human papillomavirus (HPV) take a look at or STI blood take a look at to examine for sexually transmitted an infection. A Pap take a look at is important to examine for cervical most cancers (Bowden et al., 2021). The pelvic examination will likely be important to evaluate the gynecological well being of the girl (Bowden et al., 2021).
A.
Differential Diagnoses
N87. 1: Reasonable cervical dysplasia
Cervical dysplasia includes the irregular development of cells within the cervix. The cells aren’t malignant however they are often cancerous. It may take virtually 10 years for a full most cancers analysis (Dushkin et al., 2021).
N84.1 Cervical polyp
Cervical polyps are development occurring within the cervical canal. The expansion is reddish and taking the form of a bulb. The situation happens because of an infection or excessive ranges of estrogen (Pegu et al., 2020).
C85. 91 Cervical lymphoma unspecified
Cervical lymphoma is a uncommon tumor with an prevalence of 1 % amongst cervical malignancies. One of many main signs is irregular bleeding. A cervical smear can be utilized to detect the tumor (Pegu et al., 2020).
D25.9 Leiomyoma of the uterus, unspecified
The situation includes uterine fibroids comprising of muscular tissues and connective tissue. The situation isn’t cancerous however annual monitoring is important. It’s the most typical pelvic tumor in girls (Solar et al., 2019).
P.
Efficient planning of the therapy plan must be performed to make sure the well being of the affected person. As an example, referrals are obligatory to make sure additional exams are carried out. The affected person is coming for the annual examination however additional blood and tissue exams are wanted to establish the well being situation. The interventions are obligatory to find out the situation of the vagina, cervix, and full reproductive system (Carty et al., 2020).
It will likely be essential to coach the affected person in regards to the well being dangers of sexual activity. The lady ought to be taught the necessity to apply secure intercourse with the boyfriend. She must keep away from sexual activity with a number of companions for the reason that habits can enhance the danger of HPV. It’s important to tell the affected person to ask the accomplice to be examined for sexually transmitted an infection (Carty et al., 2020). The exams are essential to take precautions or start early therapy. The precaution is important because the affected person prepares to have youngsters.
The affected person ought to go to the gynecologist inside three months and later after one yr. The aim is to look at the situation of the reproductive system, present therapy, and Assessment (Dushkin et al., 2021). It’s important to coach the affected person to all the time go to the healthcare facility yearly for a checkup. When she conceives it is going to be very important to go to a mom and little one clinic for Assessment and prenatal care.
It’s important to emphasise the necessity to get vaccinated. I’ll present nutritional vitamins to the affected person to spice up immunity to take care of good well being regardless of the danger of viral an infection. At the moment, there isn’t any Help in preparation for the being pregnant. The affected person wants to take care of good well being.
I discovered that sufferers are prone to miss deliberate visits through the pandemic. The missed visits can expose the well being of sufferers. I might encourage the affected person to come back with the accomplice after three months and yearly. The exams are very important to safe their well being, diagnose circumstances early, and supply early interventions.
In the course of the supply of care, it is going to be efficient to look at moral pointers. Moral care ought to comprise offering respectful care to the girl no matter her age and moral background (Dushkin et al., 2021). It will likely be essential to offer skilled apply to keep away from medical errors or affected person hurt.
References
Bowden, S. J., Lathouras, Ok., & Kyrgiou, M. (2021). Can DNA methylation exams enhance the accuracy of cervical screening?. BJOG: An Worldwide Journal of Obstetrics & Gynaecology, 128(three), 515-515.
Carty, M., O’Riordan, N., Ivers, M., & Higgins, M. F. (2020). Affected person views of bedside instructing in an obstetrics, Gynaecology and neonatology hospital. BMC medical schooling, 20(1), 1-9.
Dushkin, A. D., Afanasiev, M. S., Zatevalov, A. M., Aleshkin, V. A., Mironov, A. Y., Afanasiev, S. S., … & Karaulov, A. V. (2021). Digital Assessment and quantitative Assessment of the cervical floor with dysplasia. Klinicheskaia Laboratornaia Diagnostika, 66(7), 417-421.
Pegu, B., Srinivas, B. H., Saranya, T. S., Murugesan, R., Thippeswamy, S. P., & Gaur, B. P. S. (2020). Cervical polyp: evaluating the necessity of routine surgical intervention and its correlation with cervical smear cytology and endometrial pathology: a retrospective research. Obstetrics & Gynecology Science, 63(6), 735-742.
Solar, S., Bonaffini, P. A., Nougaret, S., Fournier, L., Dohan, A., Chong, J., … & Reinhold, C. (2019). How one can differentiate uterine leiomyosarcoma from leiomyoma with imaging. Diagnostic and interventional imaging, 100(10), 619-634.
