soap note

Name:

D. K

Date: 10/19/2018

Time: 1000 AM

Age: 22 y/o

Sex: Female

SUBJECTIVE

CC: “I had mild fever, nausea, vomiting, vaginal spotting and pain to my right side since last night.”

HPI: Patient is a 22-years-old female presents to the office c/o right lower abdominal pain 6-8/10 on scale of pain, since last night, accompanied with nausea, vomiting x 3, small spotting and mild fever. Gynecologic history menarche: at the age of 11, with rhythm 28 x 3, denies any STDs, G0P0A0L0, sexually active, one partner.

Medications: No.

PMH: Denies

Allergies: Denies any allergies to food or medication

Medication Intolerances: Denies.

Major traumas: Denies any trauma

Hospitalizations: Denies hospitalizations

Surgeries: Denies Surgeries

Family History

Mother: Alive, Diabetes well controlled.

Father: Alive, Healthy.

Brothers: 2 Alive and Healthy

Children: None.

Social History:

Home type: Home.

Marital status: Single

Religion: Catholic.

Tattoos: no

Alcohol: Denies.

Drugs: Denies any Drugs consumption.

Smoker: Non-smoker

Exercise: 30- 45 minutes of walk 3 times a week

Pets: No

Travel: Denies.

Blood Transfusion: Denies

OBSTETRIC/GYNECOLOGICAL HISTORY: Single, sexually active, Heterosexual, denies STI’s, Menarche: at age of 11. LMP: 08/18/2018. 28 for 4 days, regular cycle, plus the spots already described, G0T0P0A0L0, Birth Control: Yes/condom.

ROS

General

Denies any weight change in the last past 6 months denies weakness, fatigue report monthly. No distress noted at this moment, responding question in an appropriated mood. No exercise intolerance. Patient report nausea, vomiting x 3, since last night.

Cardiovascular

Patient denies chest pain and palpitation. No edema noticed no syncope, no orthopnea.

Skin

Warm and dry, skin is appropriated color for ethnicity.

Respiratory

Patient denies cough, dyspnea, wheezing or hemoptysis, no acute distress at this moment.

Eyes

Denies changes in vision, no blurred vision, no diplopia, no tearing, no scotomata, and no pain.

Gastrointestinal

No nauseas, no emesis, no dysphagia, no bowel habit changes, no melena, no constipation.

Ears

Denies ear pain, hearing loss, ringing in ears, discharge, pearly grey membranes.

Genitourinary/Gynecological

Denies dysuria, frequency or urgency. Denies blood in urine. No urinary urgency, no change in nature of urine. Vaginal spotting, since last night, no vaginal discharge. OBSTETRIC/GYNECOLOGICAL HISTORY: Single, sexually active, Heterosexual, denies STI’s, Menarche: at age of 9. LMP: 08/18/2018. 28 for 4 days, regular cycle, plus the spots already described, G0T0P0A0L0. Sexually active, one partner.

Nose/Mouth/Throat

Denies difficulty in smelling, sinus problems, nose bleeds or discharge. Denies dysphagia, hoarseness, or throat pain.

Musculoskeletal

Denies cramps, joint stiffness, arthritis or gout, limitation of movement, history of musculoskeletal or disk diseases; denies any muscle or joint pain.

Breast

Denied nipple discharge, breast pain or change in the breast skin.

Neurological

Denies history of headaches, syncope, seizures, stroke, memory disorder or mood change. No weakness, paralysis, numbness/tingling, tremors or tics, involuntary movements, or coordination problems. No mental disorders or hallucinations.

Heme/Lymph/Endo

Denies easy bruising or bleeding. No history of anemia, blood transfusions or reactions. Denies exposure to toxic agents or radiation. / Denies heat or cold intolerance, excessive sweating, polydipsia, polyphagia, or polyuria. No history of diabetes, thyroid disease, or hormone replacement.

Psychiatric

Denies depression, memory changes. Denies suicides attempts or thoughts. No history of mental illness.

OBJECTIVE

Weight:  154 lbs   

BMI: 26.4

Temp: 99.8 F

BP: 100/62 mm/Hg

Pain: 6-8/10

Height: 5’4’’

Pulse: 105 bpm

RR: 22 bpm

O2 Saturation: 99 % at Room air

General Appearance

Patient is a 22 y/o WHF, appearing of staged age; Alert and oriented; answers questions appropriately. No acute distress at this time. AAOX4, PERRLA; answers questions appropriately. Pain level: 6-/10 on scale of pain.

Skin

General appearance is normal. Normal temperature, Hydrated, no rashes or lesions described. Intact, warm, moist, good turgor. Screening for skin cancer performed no precancerous skin lesion.

HEENT

Head normocephalic, atraumatic and without lesions; hair evenly distributed. Throat: Pharynx mildly erythematous, no exudates. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa edematous, clear rhinorrhea, moderate airway obstruction. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist.

No murmur, no rubs or gallop upon auscultation.

Capillary refill 2 seconds. Regular rhythm and rate with S1, S2 normal, no S3 or S4

No edema.

Symmetric chest wall. Lungs: bilateral mildly, lungs clear upon auscultation, no rales, and no wheezes. Breath sounds equal, no rubs. No respiratory distress noted at this time.

Abdomen Soft, non-tender, BS normal in all 4 quadrants. No hepatosplenomegaly, mass, or herniation

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. No axillary nodes.

Genitourinary

Genitalia:

The bladder is non-distended; no CVA tenderness.

External genitalia reveal coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. Normally developed female genitalia. No perineal or perianal abnormalities are seen. No genital lesion or urethral discharges. No noted introitus discharge or irritation. No noted introitus discharge or irritation.

Speculum examination: A small speculum was inserted gently, Scan Vaginal bleeding, no cervix discharge, erythema, punctate hemorrhages (strawberry-patch cervix), or friability. Bimanual examination: Mobil cervix with tenderness. Bilateral adnexal palpation very painful Rt>Lf, adnexal masses noted at this time. Pelvis pain increased with a physical examination.

Steady gait, no limping or musculoskeletal deformities, or muscular atrophy. Thoracic and lumbar spine, normal. Full ROM in all 4 extremities, no joint stiffness.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; normal gait.

Reflexes 2+ bilaterally throughout.

CN II-XII intact.

Good judgment. Alert and oriented. Dressed in clean skirt and blouse. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab /Tests/Screening/Intervention/Assessment:

Laboratory /Diagnostic Test Ordered:

Urine Pregnancy test, CBC, BMP, PT/INR, PTT, HCG, Vaginal culture, Abdominal & Pelvic US.

Special Tests:  Not performed.

 Diagnosis

Ectopic Pregnancy due Clinical Presentation and Physical exam.

1. Ectopic Pregnancy (ICD 10: 000.9)

Ectopic pregnancy is an implantation that occurs in a site other than the endometrial lining of the uterine cavity in the fallopian tube, uterine cornua, cervix, ovary, or abdominal or pelvic cavity. Ectopic pregnancies cannot be carried to term and eventually rupture or involute. Early symptoms and signs include pelvic pain, vaginal bleeding, and cervical motion tenderness. Syncope or hemorrhagic shock can occur with rupture. (Merck Sharp & Dohme Corp 2017)

Differential Diagnostic:

1.- Adnexal torsion: is twisting of the ovary and sometimes the fallopian tube, interrupting the arterial supply and causing ischemia (Merck Sharp & Dohme Corp 2017)

2. – Appendicitis: is acute inflammation of the vermiform appendix, typically resulting in abdominal pain, anorexia, and abdominal tenderness. Diagnosis is clinical, often supplemented by CT or ultrasonography (Merck Sharp & Dohme Corp 2017)

3.- Dysfunctional uterine bleeding is abnormal uterine bleeding that, after examination and ultrasonography, cannot be attributed to the usual causes (structural gynecologic abnormalities, cancer, inflammation, systemic disorders, pregnancy, complications of pregnancy, use of oral contraceptives or certain drugs (Merck Sharp & Dohme Corp 2017)

Plan/Therapeutics & Education:

Plan:

1. – Assess hemodynamic stability.

2. – Monitor signs and symptoms of ectopic rupture.

3. – Evaluate contraindication and indication for medical management

4. – Expectant management: Either medical or surgical treatment:

A- Surgical management: salpingostomy or salpingectomy. Surgical management can be done by removal the affected fallopian tube called salpingectomy or by making a hole in the affected fallopian tube and pulling out the ectopic pregnancy and reserving the fallopian tube. If able a laparoscopic surgery is preferred if the patient is hemodynamically stable (Montgomery, Hannon, Muhammad, Das, & Hayes, 2017).

B- Medical management with methotrexate. According to patient’s weight she can have 50 mg methotrexate IM injection followed by lab test CBC, LFT, Beta HCG. After considering lab values especially beta HCG on day four and seven repeat dose of methotrexate. Woman should be advised not to get pregnant at least three months, when they are on methotrexate. Watch patient’s liver function in order to start the treatment and avoid alcohol and folic acid. It is chemotherapeutic agent which causes flatulence, bloating, stomatitis. Most of the patients may experience pneumonitis, bone marrow suppression, pulmonary fibrosis, liver cirrhosis, renal failure and gastric ulceration.

Teaching/Education:

Importance to maintain Hand Hygiene, General Hygiene. Diet habits and life style modification Healthy diet, Normal calorie diet or fat, increased fiber and vegetables in diet. Increase physical activity.

Cervical cancer screening should begin approximately 3 years after a woman begins having vaginal inter- course, but no later than 21 years of age. Screening should be done every year with conventional Pap tests or every 2 years using liquid-based Pap tests.

Follow-up

1. – Patient need to return to clinic if there is no improvement after 48 hours of treatment, or sooner if their condition is worsening.

2. – Follow Dr. orders and in case of emergency please call 911 or come to nearest ER.

3. – Follow up in three weeks after the surgery to evaluated patient, and laboratory testing results.

 Evaluation of patient encounter:

Interview process went well, practitioner elaborated the plan of care with patient, and education was provided and verbalized understanding.

According to Ectopic Pregnancy: Evaluation and Management. Standard Operational Procedures in Reproductive Medicine: Laboratory and Clinical Practice, “The initial evaluation of such patients is a TVS. A TVS is obtained prior to a quantitative hCG as a definitive diagnosis, such as a definite intrauterine pregnancy (IUP) or definite ectopic (EP)”(Shwayder, J. M. (2017).

Approximately 18% of all emergency-department visits for vaginal bleeding and/or acute abdominal pain are associated with ectopic pregnancies. Of these presentations, about 40% to 50% are misdiagnosed.

As signs and symptoms of it are: missed period, pelvic pain, atypical vaginal spotting or bleeding, symptoms of early pregnancy, lightheadedness, syncope, and dizziness. The patient does not know her LMP date, presents with pelvic pain, and irregular bleeding; this is further confirmed by a left adnexal mass with an echogenic ring that is seen separate from the left ovary on the obstetric ultrasound, and a HCG of 1002 (American Pregnancy Association, 2018).

Name:

Date:

Time:

Age:

Sex:

SUBJECTIVE

CC: 

Reason given by the patient for seeking medical care “in quotes”

HPI: 

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.

Medications:
(list with reason for med )

PMH

Allergies:  

Medication Intolerances:

Chronic Illnesses/Major traumas

Hospitalizations/Surgeries

“Have you every been told that you have:  Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”

Family History

Does your mother, father or siblings have any medical or psychiatric illnesses?  Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.

Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana.  Safety status

ROS

General

Weight change, fatigue, fever, chills, night sweats,  energy level

Cardiovascular

Chest pain, palpitations, PND, orthopnea, edema

Skin

Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles

Respiratory

Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB

Eyes

Corrective lenses, blurring, visual changes of any kind

Gastrointestinal

Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools

Ears

Ear pain, hearing loss, ringing in ears, discharge

Genitourinary/Gynecological

Urgency, frequency burning, change in color of urine.

Contraception, sexual activity, STDS

   Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx

  Male: prostate, PSA, urinary complaints

Nose/Mouth/Throat

Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain

Musculoskeletal

Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis

Breast

SBE, lumps, bumps or changes

Neurological

Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells

Heme/Lymph/Endo

HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance

Psychiatric

Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx

OBJECTIVE

Weight        BMI

Temp

BP

Height

Pulse

Resp

General Appearance

Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.

Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.

HEENT

Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. 

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.

Genitourinary

Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.  No adnexal masses or tenderness. Ovaries are non-palpable.

(Male:  both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )

(Rectal as appropriate:  no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).

Full ROM seen in all 4 extremities as patient moved about the exam room.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

Urinalysis – pending

Urine culture – pending

Wet prep – pending

Special Tests

Diagnosis

 Differential Diagnoses

· 1-

· 2-

· 3-

Diagnosis

Plan/Therapeutics

· Plan: 

· Further testing

· Medication

· Education

· Non-medication treatments

 Evaluation of patient encounter