SOAP NOTE
Age in years: 42 Gender: Female
Subjective
CC (Chief Complaint): A 42 year old female presented to the Gynaecology clinic with the complaint of severe pain in abdomen with heavy menstrual bleeding (on the 3rd day of the menstrual cycle).
History of Present Illness: The patient was apparently well almost 3 months back when she gradually developed extreme pain in the lower abdomen prior to and during the menstrual cycle. The cycles were normal before these three months. She never had such excruciating pain before. The pain used to commence a day or two prior to the cycles and continued throughout the cycle. The pain often radiated down to the upper parts of the thighs or to the lower back. Bleeding was heavy, clotted, dark red and offensive. She had to use 6- 7 sanitary napkins in a day. Bleeding was more profuse on lying down.
PMFSH (Past medical/ family/ social history):
Travel History past 30 days: No recent travels within the last 30 days
Current Medications (Complete with dosing and route): Taking calcium supplements, recommended by family physician
Allergies (Medication, Food, Environmental): Not allergic to any medication, food or environmental influences
Health Screenings appropriate for age: Underwent screening test for Breast CA: Normal
Immunizations: Received all the necessary immunizations on time
Past History: Had knee recurrent knee pain since the age of 35 for which she was recommended to take calcium supplements. No other major illness in the past recorded.
Childhood illness: No major childhood illness except an episode of chicken pox which lasted for 6-7 days.
Adult Illness: No history of adult illness
Medical History: No medical history
Hospitalizations: No history of hospitalizations
Surgical History: Had undergone two Caesarean sections during the birth of her two children.
Sexual History: She is in a monogamous relationship with her husband since the last 20 years. She never had any other sexual partner other than him. No history of sexually transmitted diseases in the family.
OB/GYN:
G P (TPAL): Gravida- 2, Para- 2, Abortion- Nil, Live children- 2
Last PE: Do not remember
Last Pap/ Results/Treatment: Never done
Menarche: 12 years of age
Hx STDs: No history of STD
Contraception: She had Copper T inserted for almost 17 years. Got it removed 2 years back as she believes it is not needed anymore due to lack of sexual intimacy between her and her husband.
Mammogram: Done 5 years back, was found to be normal.
Psych History: No family Psych history.
Family History: Both of her parents have died naturally with no serious illness. Her children are healthy and alive.
Social History/Harm Assessment: The patient stays in an apartment with her husband and two teenage children. They have a peaceful home environment with no familial discords. She never steps out of the house without applying sunscreen. Likes to keep herself physically active and fit by doing yoga and meditation.
Home Safety: Have smoke and carbon monoxide detectors at home
Sleep: She sleeps for 7- 8 hours at night with a short nap of 30- 45 minutes in the afternoon.
Physical Activity: Keeps herself physically active by indulging in household chores and yoga
Depression Screen: No concerns about depression noted. She is a calm and composed person.
Review of Systems
General: She denies any weight loss, change in appetite, fever and chills.
Skin: No rashes, lesions or wounds
Eyes: Normal vision. No discharge, redness or pain. No photophobia, double vision or Cataract.
Ears: No hearing problems. No tinnitus. No swelling or redness in or around the ears. No pain, no discharge.
Nose: No nasal deviation. No runny nose. No alteration in smell.
Mouth and throat: No dental caries, oral mucosa inflammation or lesions. No problem in swallowing or sore throat.
Respiratory: No shortness of breath or cough
Gastrointestinal: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood in stool
Genitourinary: No dysuria
Neurology: No seizure or weakness
Hematology: No pallor, pica, spontaneous or easy bruising and/or bleeding. No prolonged or excessive bleeding, purpura or petechiae.
Musculoskeletal: No joint swelling. Pain in lower abdomen, lower back and upper parts of thighs during and before menses.
Psychiatry: No mental disorders
Objective:
VS: T- 98.4, P- 74/ min, Resp- 18/ min, O2 sat- 98% on room air
Weight: 60 Kg
Height: 164 cm
BMI: 22
Vision: 6/6, No strabismus, pupils equal round and reactive to light. No edema of eyelids, no crusting bilaterally. No watery discharge
Urinalysis: Both routine and microscopic urine examination was found to be normal.
General Statement: The patient is calm and composed. She is cooperative. There is some sign of pain on her face, otherwise she is completely under control of her senses and in no acute distress.
Mental Status: Calm and cooperative.
PE: Head to Toe:
Ears: external canals with no discharge or drainage. Tympanic membranes without erythema with good cone of light bilaterally
Nose: Nares no discharge, moist nasal mucosa.
Mouth and throat: moist oral mucosa, no exudates, uvula midline. oropharynx clear with no lesions or erythema. No palpable/enlarged lymph nodes;
Abdomen: Soft, without organomegaly. Bowel sounds normal. No masses palpable. No distention.
CV: Regular rate and rhythm. Normal S1 and S2. No murmurs, gallops, or rubs. No peripheral cyanosis or edema
Genitalia: Normal female external genitalia. No sign of any redness or swelling. Per vaginal examination could not be performed as the patient was menstruating.
Working Diagnosis
Uterine Fibroid: The most probable diagnosis for this case can be uterine fibroid as many symptoms of the patient resemble those of fibroid. The age of onset, nature of bleeding, and pain point towards the possibility of this particular disease condition (Mayo Clinic Staff, 2016).
Differential Diagnosis:
Endometrial carcinoma: This may be a possibility as the manifestations are almost similar with that of the patient. Additionally, being a serious condition, it should be ruled out at the earliest.
Adenomyosis: Very similar manifestations, differentiating between adenomyosis and fibroid is not possible without biopsy and ultrasound.
Ovarian cancer: Ovarian cancer has similar manifestations, but it is often accompanied by weight loss which is not evident in this patient (BMJ, 2016).
Plan:
Interventions:
The patient was asked to take hot compresses
The patient was taught about different relaxation techniques like deep breathing
The patient was asked to keep herself indulged in various activities in order to divert her mind (Nursing Diagnosis Intervention, 2016)
Diagnostics
Make the patient undergo an abdominal ultrasonography
The patient should also go for a biopsy following the results of the ultrasound.
Prescriptions and Therapeutics
Treatment will consist of hot compress and analgesics.
Education/Anticipatory Guidance and Counseling
Referrals: None
Follow-up
Telephone or office follow-up in 24 hours to assess effectiveness of treatment.
Return to clinic if no improvement in 5 days or if symptoms worsen.
Routine follow-up not needed if symptoms resolve.
Reflection: Uterine fibroid is a relatively harmless condition which is often seen in the women of child bearing age. The patient in this case is most likely to suffer from this condition. However, I cannot label the case as uterine fibroid unless I receive diagnostic results. Till then I would keep her on analgesics and hot compresses. After the reports are obtained, I will decide the line of treatment. Depending on the cause and nature of the disease condition I will decide if I should go ahead with hormonal replacements or should make the patient undergo surgical treatment.
Medication List:
Ibuprofen: 400mg to be taken orally, after every four to six hours
Indicated in generalised pain, osteoarthritis, dysmenorrhea etc.
Side effects: Vomiting, bleeding, anemia
Naproxen: 550mg to be taken orally after every 12 hours
Indicated in gout, inflammatory conditions, bursitis etc.
Side effects: Indigestion, rashes, dyspnea.
References
BMJ Best Practice. (2016). Bestpractice.bmj.com. Retrieved 1 April 2016, from http://bestpractice.bmj.com/best-practice/monograph/567/diagnosis/differential.html
Mayo Clinic Staff,. (2016). Uterine fibroids Symptoms - Mayo Clinic. Mayoclinic.org. Retrieved 1 April 2016, from http://www.mayoclinic.org/diseases-conditions/uterine-fibroids/basics/symptoms/con-20037901
Nursing Diagnosis Intervention: Uterine Fibroids - Nursing Interventions Acute Pain. (2016). Nursing Diagnosis Intervention. Retrieved 1 April 2016, from http://nursing-diagnosis-intervention.blogspot.in/2012/05/uterine-fibroids-nursing-interventions.html
