SOAP NOTE
Women’s Health / Primary Care SOAP
Age Range: 20-30 Gender: Female
Occupation: Home maker.
Subjective:
ID: M.M.
Reliability: Pt is reliable, dependable and a knowledgeable source of information.
Reason for seeking Care (CC): Patient states “I have missed last two menstrual cycles of mine. I just need to confirm if I am pregnant.”
History of Present Illness: Patient is a 29-year-old Asian female with no significant medical illness in the past history. Patient is a new patient to the clinic, and has come to confirm if she is pregnant.
Travel History past 30 days: Patient has returned from a trip to her home land last week..
Current Medications: She uses some Homoeopathic medicines for constipation and heartburn sometimes.
Allergies (Medication, Food, Environmental): No allergy to any medication, food or any other environmental influences.
Immunizations: Patient do not have any idea regarding her immunization schedule. Her immunization charts are kept away at her homeland in the custody of her mother.
HPV: Never taken
Past Medical History: Childhood illness: Nil Adult Illness: Nil Medical History: Nil Hospitalizations: Nil Surgical History: Sexual History: Patient is currenlty sexually active, in a monogamous heterosexual relationship with her husband of 2 years. She takes Oral Contraceptive pills regularly, but admits missing the pills on multiple occasions during her stay in her homeland. She and her husband did get involved sexually with each other. Denies using any condom, or other form of preventive measures against STDs. No dyspareunia. Total number of lifetime partners is 2.
OB/GYN: G P (TPAL): G0 P0 Last Breast Exam: Not performed Last Mammogram: Not performed Last Pelvic Exam: Not performed Last Pap/ Results/Treatment: Not Applicable LMP: 2/12/16 Menarche: 13 Coitarche: 23
Hx HIV&STDs: No history of any Sexually Transmitted Diseases (STDs). Tested negative with the sample taken on 06/01/2015). Contraception: Takes Oral Contraceptive Pills almost daily. Self-Breast Examination (SBE): Occasionally performs monthly self-breasts examinations Psych History: Nil Family History: Mother is hypertensive (diagnosed at the age of 35 years, living at the age of 52 years). Father is diabetic (diagnosed at the age of 38 years, living at the age of 56 years).
Social History: She is a home maker. She is a teetotaler and never smokes. Belonging to an Asian country, she is quite a religious and somewhat superstitious person.
Harm Assessment: She applies sunscreen whenever stepping out of home. Home Safety: The patient stays in an apartment with her husband. They share a normal husband- wife relationship. Their home environment is congenial and peaceful.
Sleep: Sleeps for 8 hours at night and for 2 hours in the afternoon. Reports feeling well rested on awakening.
Physical Activity: States she never works out; goes for walks in a nearby park once or twice a week.
Diet: Takes 3 meals a day with light snacks in between. Depression Screen: The patient is a calm and composed person with no apparent signs of depression.
Review of Systems
General: No fever, no chills, no fatigue and no apparent weight changes.
Skin, Hair, & Nails: No changes in moles, no rashes, no pruritis, no lesions and no hair loss. No changes in th skin texture and no sign of any pigmentation. No change in the appearance of nails.
Breasts: No warmth, no palpable masses, no lumps, no pain in any of the breasts, no erythema, no nipple discharge. No changes in the breast size and no variation in the size, no dimpling or no change in pigmentation.
Respiratory/Thoracic: No cough, no wheezing, no shortness of breath, no dyspnea at rest or on exertion.
Cardiovascular: No chest pain, no palpitations, no tightness and no discomfort. No arrhythmia and no murmurs.
Peripheral Vascular: No peripheral edema on any of the extremities; upper or lower, no pain, no paresthesia, no warmth, no coolness, and no thrombosis.
Gastrointestinal/Abdomen: No nausea, no vomiting, no diarrhea, no constipation. No dyspepsia, no blood in stool or any change in stool.
GU/OB/GYN: No genital lesions, no bumps, no lumps, and no pain during intercourse. No history of any sexual abuse, rape, or any form of domestic violence.
Urinary: No changes in urinary frequency, no urgency, no burning, no decrease in stream, no hematuria and no abnormal odor in urine.
Hematological: No history of anemia, no spontaneous or any easy bruising and/or bleeding. No prolonged or excessive bleeding, no purpura or petechiae. No history of transfusions and no syncope.
Endocrine: No intolerances to any extremes of hot and cold. No changes in appetite, no polyuria, no polydipsia and no polyphagia.
Psychiatric: No anxiety, no depression, no personality disorders, no hallucinations, no bipolar, suicidal ideations and no such attempts in the past.
Objective:
VS: BP- 120/80, HR -76/ min, RR-19/ min, Temp-36.4. Pain 0/10 (verbal pain scale). VS recorded by staff nurse. Weight: 137lbs. Height 65.1in. BMI-23.0 Vision: 20/20 Normal for both eyes. Urinalysis: Clarity- clear. Color- pale yellow. Glucose- Absent. Bilirubin – Absent. Ketones –Absent. General Statement: No symptoms of any distress or any emergent conditions noticed. Skin: normal skin tone according to the ethnicity of the patient, normal temperature and normal skin texture.
Affect and mood appropriate. Dress up, hygiene, and grooming of the patient is appropriate and without any odor.
Patient is ambulatory with a smooth and a steady gait. And she appears to be her stated age.
Mental Status: Patient is alert and well oriented x3. Calm. Cooperative. Speech is clear, coherent, and not slurred.
Physical Exam:
Head: Normocephalic, without any lumps or bumps. Hair is black in color, with smooth texture and an even distribution.
Abdominal: Soft and non- tender abdomen, spleen and kidneys are impalpable. Aorta is not palpable. Bowel sounds audible in all the 4 quadrants. No palpable masses. No distention of abdomen. No CVA tenderness.
Cardiovascular: Regularity in rate and in rhythm. Normal S1 and S2. Murmurs absent, gallops absent, no rubs. No peripheral cyanosis and no edema
Breast: Pain absent, no lumps or nipple discharge. Impalpable lymph nodes, no tenderness bilaterally. Breasts are symmetrical, without any dimpling, no nipples everted.
Pelvic:External genitalia was normal, without any anatomical anomalies. Erythema absent, lesions and masses absent. Vaginal mucosa and cervix is moist and normal. Nulliparous cervix. No adenopathy of inguinal region. Uterus is midline. No tenderness on cervical motion.
Rectal:Deferred
Working Diagnosis: The most probable diagnosis in this particular case can be pregnancy. Absence of menstruation since the last two months in a woman of the reproductive age group points towards this particular diagnosis. In addition to that, the female has admitted missing her oral contraceptive pills multiple times in the last few days along with indulging in unprotected intercourse which further increases the chance of her being pregnant.
Differential Diagnosis:
PCOS: Nowadays, PCOS has become quite a common disease among young and reproductively active females. Amenorrhea does point towards this common disease to certain extent, however, there were not many symptoms of the patient which can help in confirming the diagnosis. Ultrasound of the lower abdomen is necessary in order to reach to a conclusion (WebMD, 2016).
Anaemia: Anaemia is again another important cause which may lead to amenorrhea. The occurrence of anaemia among the Asian females tends to be higher than many other continents and countries. It is thus important to test the patient for anemia (Raghuraman and Rathika, 2001).
Mental and Physical Stress: The patient has recently travelled back from her homeland. She has undergone through physical strain during her travel. She has also been through some form of emotional stress while leaving her family back in Asia. This can thus be an important cause of the amenorrhea she is experiencing. In case, the reason for amenorrhea is stress then the condition may resolve within few days without any treatment (Mayo Clinic Staff, 2016).
Plan: Interventions: 1) The patient was educated on the phenomenon of amenorrhea following mental and physical stress.
2) She was encouraged to use contraceptive pills without any miss.
3) She was advised to use condoms in order to prevent STDs.
4) The patient was also asked to undergo routine breast examination, Pap smear and general health checkups as she has high chances of developing diabetes and hypertension due to a positive family history.
Diagnostics 1) Urine Pregnancy Test 2) Complete blood count
3) Lower abdominal ultrasound
Prescriptions and Therapeutics: No treatment needed at this time
Referrals: None
Follow-up: 1) Call office if any concerns. 2) Report after receiving the reports.
Reflection: Under my preceptors supervision I performed this patient’s annual physical exam today. I also had the opportunity of counseling this patient. The patient appeared to be almost sure of her pregnancy. This gives an idea that the pregnancy is not an unwanted one.
My goal for next week is to work on improving my interpersonal and communication skills during a gynecological exam. As well as also learning how to counsel patients regarding individual life style choices that contribute to the patients’ optimal health in a respectful non-aggressive manner.
Medication List:
Multivitamin tablets available as OTC drugs can be taken in this case as the patient does not need any specific medication unless the reports are obtained. However, the patient should not take more than the required dosage.
2 tablets a day for a period of one week will suffice.
References
Mayo Clinic Staff,. (2016). Amenorrhea Causes - Mayo Clinic. Mayoclinic.org. Retrieved 29 April 2016, from http://www.mayoclinic.org/diseases-conditions/amenorrhea/basics/causes/con-20031561
Polycystic Ovary Syndrome (PCOS)-Topic Overview. (2016). WebMD. Retrieved 29 April 2016, from http://www.webmd.com/women/tc/polycystic-ovary-syndrome-pcos-topic-overview
Raghuraman, V. & Rathika, V. (2001). Secondary Amenorrhoea: Nutritional Anaemia a Cause or Reason. Comparative Haematology International, 10(4), 208-211. http://dx.doi.org/10.1007/s005800170007
