Womens Health Soap Note X4 (Due 24 hours)
1) Submit 1 document per part
Symptoms or diagnoses such as “normal” or “abnormal” are not allowed, you must address ROS and physical examination comprehensively.
Part 1: Complete the file 1 taking into account the following information:
Diagnosis: Endometriosis
Female
29 Years
Part 2: Complete the file 1 taking into account the following information:
Diagnosis: Uterine Fibroids
Female
42 Years
Part 3: Complete the file 1 taking into account the following information:
Diagnosis: Cystitis
Female
28 years
Part 4: Complete the file 1 taking into account the following information:
Diagnosis: Sexually Transmitted Diseases
Female
22 years
2)¨******APA norms, please use headers
All Diagnosis and differential diagnosis must be narrative and cited in the text- each paragraphs
Bulleted responses are not accepted
Dont write in the first person
Dont copy and pase the questions.
Submit 1 document per part
3) It will NOT be verified by Turnitin or SafeAssign
4) Minimum 3 references per part not older than 5 years
5) Symptoms or diagnoses such as “normal” or “abnormal” are not allowed, you must address ROS and physical examination comprehensively.
SOAP NOTE
Patient Initials: |
Pt. Encounter Number: |
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Date: |
Age: |
Sex: |
Allergies: Advanced Directives: |
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SUBJECTIVE |
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CC: In quotation marks indicate the patient’s complaint |
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Follow the example. You must address the fundamental aspects of the patient, such as age, complaint, symptoms, time with symptoms, health problems …
HPI: |
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Current Medications: Indicate if the patient is consuming any medication. |
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Follow the lead according to the disease PMH
Medication Intolerances:
Chronic Illnesses/Major traumas:
Screening Hx/Immunizations Hx:
Hospitalizations/Surgeries: |
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Follow the lead according to the disease
Family History Mother died of kidney disease. |
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Follow the lead according to the disease
Social History: |
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Follow the lead according to the disease In this case, the symptoms should focus on “Genitourinary / Gynecological” and other related systems- symptoms that the patient refers to their disease. You must use different wording to complete “ROS” ROS |
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General Alert no change in physical appearance, strength, weight and no fever and chills |
Cardiovascular No chest pain, no palpitations, no orthopnea. Regular rhythm, pulse rate normal |
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Skin Normal , in color, no lesion, no rash. |
Respiratory No cough, sputum, chest normal in shape, no abnormal breathing sound. |
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Eyes Normal vision, denied any pain and blurred vision |
Gastrointestinal Normal appetite, normal bowel habit. |
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Ears Denied from vertigo, change in hearing, tinnitus. |
Genitourinary/Gynecological |
Nose/Mouth/Throat Nose: No obstruction. No discharge, denied bleeding, no epistaxis. Mouth: normal mucosal lining. Throat: Normal in shape, no abnormal mas found. |
Musculoskeletal Occasional lower back pain, denied any joint or muscle pain. |
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Breast Normal |
Neurological Intact sensory and motor system, normal DTR |
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Heme/Lymph/Endo Normal, no swelled lymph nodes. Normal thyroid gland. |
Psychiatric Normal, denied any type of psychiatric issue. |
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OBJECTIVE Follow the lead according to the patient |
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Weight 174 lb. BMI 30.82 |
Temp 97.90 F |
BP 139/78 mmhg |
Height 63” |
Pulse 64 bpm |
Resp 18bpm |
PHYSICAL EXAMINATION Follow the lead according to the disease |
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General Appearance Alert and oriented x 3. The patient is well-groomed, who responds to questions quickly and appropriately. She is dress appropriate to the occasion and has a normal posture. |
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Skin
Normal in color and texture |
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HEENT Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. No aphasia receptive or expressive. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movement intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions. Lids non-remarkable and appropriate for race. Neck negative for masses, no noticeable or palpable swelling, redness or rash around throat or on face. No thyromegaly. No JVD distention. Teeth are in good repair |
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Cardiovascular
No splitting of the heart sounds heard. No murmur. No S3 or S4. No friction rubs. Patient denies chest pain. S1, S2 with regular rate and rhythm. No extra heart sounds. No SOB, no JVD, no carotid bruits. |
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Respiratory
Symmetric chest walls. Respirations regular and easy. Clear to auscultation, no use of accessory muscles, no crackles or wheezes. |
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Gastrointestinal
Abdomen flat, soft, no painful to palpation. BS active in all 4 quadrants. No hepatosplenomegaly |
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Breast
No mass noted, no fulness sensation, pain, or discharge reported. No prior history of breast biopsy, lesions, pain, or discharge. |
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Genitourinary |
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Musculoskeletal
No history of falls reported, denies weakness, muscular pain, swollen ,or any other inflammatory symptoms in the joints. Denies joint pain, limited ROM, difficulty walking, or trouble reaching above head. |
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Neurological
Denies history of seizure disorder, stroke, head injury, tremors, or involuntary movements, vertigo, spinal cord injury, meningitis, blackouts, paralysis, fainting, dizziness, numbness, or loss of sensation. The memory is good. |
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Psychiatric
Patient states no changes in mood, denies anxiety, depression, or insomnia. Denies low self-esteem, feeling sad, social isolation, or attention deficit, no change in thought patterns. |
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Lab Tests Follow the lead according to the disease MRI of back, X-ray of spine, CBC, Urinary analysis, Lipid profile. |
Special Tests: Follow the lead according to the disease X-ray of Spine, MRI of lumber spine. |
Diagnosis Follow the lead according to the disease |
· Primary Diagnosis Follow the lead according to the disease Abscess of bartholin’s gland (ICD 10-N 75.1): Bartholinitis occurs when the ostium duct of Bartholin’s gland is blocked, and it becomes infected. If the cyst is small and there is not infection usually it is asymptomatic but, ones the cyst increases in size, or become infected, patients start to feel a tender, painful lump near to the vaginal opening. Usually the pain and discomfort increase with walking and sitting, and patients also present dyspareunia and fever. Based on the patient’s subjective assessment, I suspect that the patient is the holder of this condition (Charleton, Otero, Giorgi & Tyndall, 2016). · Differential Diagnosis (minimum 3 differential diagnosis and 3 references) Follow the lead according to the disease Trichomoniasis (ICD 10-A59.01): Sexually transmitted infection of the urogenital tract is a common cause of vaginitis in women, while men with this infection can display symptoms of urethritis. ‘Frothy’, greenish vaginal discharge with a ‘musty’ malodorous smell is characteristic. PLAN including education Follow the lead according to the disease |
References:
Clinic, M. (2020, June 11). Kyphosis. Retrieved from MayoClinic: https://www.mayoclinic.org/diseases-conditions/kyphosis/symptoms-causes/syc-20374205 |