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Case Study On Gynecological Health SOAP Note Template

Case Study On Gynecological Health SOAP Note Template

Subjective Data

Chief Complaint: “ can we discuss contraceptive options?”

History of presenting illness: Elaine Goodwin is a 38-year-old white female who came to the clinic to discuss contraceptive methods. She is not willing to have children but she recently married a man who has no children. She states that she wants an effective birth control method without adverse effects. She adds that her previous contraceptive methods; Implanon, combined oral contraceptives, and Depo injection made her lose weight, and have heavy intra-menstrual cycle bleeding, and headaches Case Study On Gynecological Health SOAP Note Template.

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Current medication: vitamin C

Allergies: she denies food and drug allergies

Past medical history: she has exercise-induced asthma, migraines, and IBS. She has had hospital admissions during childbirth.

Surgical history: tonsillectomy in her childhood

Family history: Elaine Goodwin is the second child in a family of three children. Her father is alive with a history of basal cell skin cancer. Her mother I alive with a history of osteopenia and fibromyalgia. Her elder sister and younger brother have no reported medical problems. Her maternal grandmother is living with dementia and her maternal grandfather has COPD.

Social history: Elaine Goodwin is newly married. She has children from her previous relationship. she has a bachelor’s degree in accounting and is currently working as a banker. She enjoys reading novels, swimming, and riding bicycles. She takes healthy home-prepared meals. She uses seatbelts while in a vehicle and does not use a phone when driving or walking on a pathway. She denies the use of alcohol, tobacco, and other recreational drugs.

Psychiatric history: the patient denies anxiety attacks, depressive mood, post-traumatic stress disorder, and psychosis.

Violence history: the patient denies episodes of personal and public attacks, cyberbullying, and sexual harassment.

Reproductive history: her menarche was at 15 years old. She has been having a regular 28days cycle with four days of moderate flow. Her last menstrual period was on 1/6/2022. She experiences mild lower abdominal cramping and breast tenderness during her menstrual flow. she has been using coitus interruptus with her current partner. She has three children born at term via spontaneous vertex delivery. She denies post-partum complications.

Sexual history: the patient is sexually active and engages in penetrative vaginal intercourse at least three times a week. She has had three sexual partners since her first encounter at the age of 20 years. She denies a history of sexually transmitted diseases, dysuria, hematuria, vaginal discharge, post-coital bleeding, and dyspareunia.

Review Of Systems

General: the patient denies fatigue, weight loss, chills and rigors, night sweats, and fever.

HEENT: The patient denies headache, blurring of vision, loss of hearing, running nose, throat pain, and neck swelling.

Respiratory system: she denies coughing, chest pain, wheezing, sputum production, tachypnea, and difficulties in breathing.

Cardiovascular system: the patient denies palpitations, syncope, lower limb swelling, orthopnea, paroxysmal nocturnal dyspnea, and tachycardia.

Gastrointestinal system: the patient denies abdominal pain, heartburn, reflux, bloating, nausea, vomiting, constipation, diarrhea, and loss of appetite.

Genitourinary system: the patient denies dysuria, hematuria, polyuria, urgency, vaginal discharge, vaginal itchiness, and flank pain.

Neurological system: the patient denies facial droop, peripheral numbness, dizziness, muscle weakness, and changes in bowel control.

Musculoskeletal: the patient denies muscle pain, joint pain, joint stiffness, and muscle spasm Case Study On Gynecological Health SOAP Note Template.

Lymphatics: the patient denies enlarged nodes, recurring infections, and splenomegaly.

Psychiatric: the patient denies low self-esteem, insomnia, anxiety, depressive mood, and psychotic disorder.

Endocrine system: the patient denies heat and cold intolerance, weight gain, stretch marks, sweating, and irritability.

Hematologic: she denies bleeding tendencies, easy bruising, and anemia.

Skin: she denies skin color change, itchiness, and rash.

Objective Data

General examination: the patient is calm and alert. He has no pallor, jaundice, dehydration, cyanosis, edema, or lymphadenopathy.

Vitals: her blood pressure is at 118/72mmHg, her pulse rate at 68beats per minute, weight 148Ibs, weight 5’7, BMI 23.1.

HEENT: the head is round with no scars and wounds. She has no conjunctivitis, ear discharge, post nasal drip, and swollen tonsil gland.

Neck: the neck is supple with no adenopathy.

Respiratory systems: the chest wall has symmetrical expansion when breathing in. The chest wall has no mass or scars. There is a resonant percussion note and vesicular breath sounds. There is no tachypnea, rhonchi, stridor, and crackles.

Cardiovascular system: the heart is palpable at the 5th ICS. There are n parasternal heaves and thrills. The heart sounds S1 S2 is present without murmurs. The peripheral pulses are present with a regular rhythm and rate.

Abdominal examination: the abdomen is round with a normal contour, no mass, and no striae. The bowel sounds are present in the four quadrants. There is a tympanic percussion note at the abdomen. There is no shifting dullness and fluid thrills. The liver span is 1cm below the costal margin. There is no organ enlargement.

Breast examination: the breasts are soft with fibrocystic changes bilaterally, without masses, dimpling, and discharge.

Cervix: the cervix is firm, parous, and without cervical motion tenderness.

Uterus: she has retroversion of the uterus that is mobile, non-tender, and 10cm in size.

Adnexa: the adnexa has no mass, fluid accumulation, and tenderness.

VVBSU: within the normal limit but has a 1st-degree cystocele

Diagnostic Tests

  1. Complete blood count to rule out systemic infections, and check the hemoglobin levels, and platelet levels.
  2. Pregnancy test to rule out pregnancy
  3. Thyroid function test to rule out hypothyroidism and hyperthyroidism
  4. Random blood sugar to check the glycemic control
  5. Lipid profile to rule out hypercholesterolemia
  6. Breast mammogram to rule out breast cancer
  7. Erythrocytic sedimentation rate to rule out chronic diseases

Assessment

Differential Diagnoses

  1. Fibrocystic breast disease
  2. Breast cyst
  3. Fat necrosis

Fibrocystic breast disease is a benign disease of the breast that presents with a lumpy texture of the breast, tenderness, and enlargement of the nodules before menstrual periods and gets better at the beginning of a new cycle. It is common in women between 30 to 50years old. Causes are fluctuating hormonal levels, fluid fill cysts, hyperplasia of the milk duct, and enlarged breasts lobules (Kohnepoushi, et al, 2022). This is the patient’s primary diagnosis because she is above 30 years old and experiences breast pain and tenderness during her menstrual flow. On examination, her breasts are soft with fibrocystic changes and no nipple discharge.

Fat necrosis is a non-cancerous breast lump that develops in the breasts from dead or damaged breast tissue. Causes of death or damage to the breast tissues are fine needle aspiration, biopsy, breast infection, smoking, obesity, old age, chemotherapy, and breast reconstruction (Lee, et al, 2021). The presenting symptoms are firm mass or lamp, bruising of the breast tissue, nipple discharge and inversion, thickening of the breast skin, and swollen lymph nodes. This is not the actual diagnosis because the patient neither has the symptoms nor the risk factors of the disease Case Study On Gynecological Health SOAP Note Template.

A breast cyst is a benign mass of the breast that causes a breast lump. It may develop on one or both breasts causing pain and discomfort. They appear naturally at all ages but are most common after 35years old (Berg, W. A. 2021). They change due to hormonal change in size, becomes sore, and feels tender, especially during menstrual flow. The actual diagnosis is made after histopathology by fine-needle aspiration, core needle biopsy, and mammogram. This is not the diagnosis because the patient does not feel a breast lump.

Plan

Contraception Counseling

The patient is well informed of contraception methods; coitus interruptus, implant, combined oral contraceptives, and depo injection. However, these are not effective methods for her because of the side effects she has had. I would recommend she use intra-uterine devices like copper T because it does not have hormonal effects on the body. They can last up to five years with no side effects like hypertension, deep venous thrombosis, obesity, and hyperglycemia (Herrera, et al, 2019). There are no drug interactions that lowers its effectiveness, unlike hormonal contraceptives. Intra-uterine devices may cause health menstrual flow and abdominal cramping (Ouyang, et al, 2019). it does not need regular weight, blood pressure, and blood sugar monitoring. The patient can withdraw the method when the need to conceive arise. It is not associated to ectopic pregnancies and

Pharmacology Treatment

  1. Ibuprofen 400mg PO three times daily for abdominal cramping and breast tenderness.

Reflection

Assessing the patient was a good learning experience for me. Fibrocystic breast changes are common in female adults and may cause cancer most of the time. However, all women need a regular mammogram to rule out or detect malignant breast tissue. In the future, I will be equipped with more information to make an appropriate diagnosis and order investigations. Women should be aware of the benign breast changes to ensure they do self-examination and a regular check for early diagnosis and treatment.

Elaine Goodwin is a 38-year-old G5P5006  presenting to your clinic today to discuss contraceptive options.  She states that she is not interested in having more children but her new partner has never fathered a child. Her medical history is remarkable for exercise-induced asthma, migraines, and IBS. Her surgical history is remarkable only for tonsils as a child. Her social history is negative for alcohol, tobacco, and recreational drugs.  She has no known drug allergies and takes only vitamin C. Hospitalizations were only for childbirth. Family history reveals that her maternal grandmother is alive with dementia, while her maternal grandfather is alive with COPD. Her paternal grandparents are both deceased due to an automobile accident. Her mother is alive with osteopenia and fibromyalgia, and her dad is alive with a history of skin cancer (basal cell). Elaine has one older sister with no medical problems and one younger brother with no reported medical problems. 

• Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 P 68 
• HEENT:  wnl 
• Neck: supple without adenopathy 
• Lungs/CV: wnl 
• Breast: soft, fibrocystic changes bilaterally, without masses, dimpling or discharge 
• Abd: soft, +BS, no tenderness 
• VVBSU: wnl, except 1st degree cystocele 
• Cervix: firm, smooth, parous, without CMT 
• Uterus: RV, mobile, non-tender, approximately 10 cm, 
• Adnexa: without masses or tenderness 

Main Posting:

Response to the case study discussion questions includes appropriate diagnoses with explanations of appropriate diagnostic tests and treatment options as directed, is based on evidence-based research where appropriate, and is incorporates syntheses representative of knowledge gained from the course readings for the module and current credible sources.– Case Study On Gynecological Health SOAP Note Template

Excellent
Point range: 90–100 40 (40%) – 44 (44%)
Good
Point range: 80–89 35 (35%) – 39 (39%)
Fair
Point range: 70–79 31 (31%) – 34 (34%)
Poor
Point range: 0–69 0 (0%) – 30 (30%)
Main Posting:

Writing–

Excellent
Point range: 90–100 6 (6%) – 6 (6%)
Good
Point range: 80–89 5 (5%) – 5 (5%)
Fair
Point range: 70–79 4 (4%) – 4 (4%)
Poor
Point range: 0–69 0 (0%) – 3 (3%)
Main Posting:

Timely and full participation–

Excellent
Point range: 90–100 9 (9%) – 10 (10%)
Good
Point range: 80–89 8 (8%) – 8 (8%)
Fair
Point range: 70–79 7 (7%) – 7 (7%)
Poor
Point range: 0–69 0 (0%) – 6 (6%)

References

Berg, W. A. (2021). BI-RADS 3 on screening breast ultrasound: what is it and what is the appropriate management?. Journal of Breast Imaging, 3(5), 527-538.

https://doi.org/10.1093/jbi/wbab060

Herrera, A. Y., Faude, S., Nielsen, S. E., Locke, M., & Mather, M. (2019). Effects of hormonal contraceptive phase and progestin generation on stress-induced cortisol and progesterone release. Neurobiology of stress, 10, 100151. https://doi.org/10.1016/j.ynstr.2019.100151

Kohnepoushi, P., Dehghanbanadaki, H., Mohammadzedeh, P. et al. The effect of the polycystic ovary syndrome and hypothyroidism on the risk of fibrocystic breast changes: a meta-analysis. Cancer Cell Int 22, 125 (2022). https://doi.org/10.1186/s12935-022-02547-5

Lee, J., Park, H.Y., Kim, W.W. et al. Natural course of fat necrosis after breast reconstruction: a 10-year follow-up study. BMC Cancer 21, 166 (2021). https://doi.org/10.1186/s12885-021-07881-x

Ouyang, M., Peng, K., Botfield, J. R., & McGeechan, K. (2019). Intrauterine contraceptive device training and outcomes for healthcare providers in developed countries: A systematic review. PloS one, 14(7), e0219746. https://doi.org/10.1371/journal.pone.0219746

Subjective Data

Chief Complaint: “ can we discuss contraceptive options?”

History of presenting illness: Elaine Goodwin is a 38-year-old white female who came to the clinic to discuss contraceptive methods. She is not willing to have children but she recently married a man who has no children. She states that she wants an effective birth control method without adverse effects. She adds that her previous contraceptive methods; Implanon, combined oral contraceptives, and Depo injection made her lose weight, and have heavy intra-menstrual cycle bleeding, and headaches.

Current medication: vitamin C

Allergies: she denies food and drug allergies

Past medical history: she has exercise-induced asthma, migraines, and IBS. She has had hospital admissions during childbirth.

Surgical history: tonsillectomy in her childhood

Family history: Elaine Goodwin is the second child in a family of three children. Her father is alive with a history of basal cell skin cancer. Her mother I alive with a history of osteopenia and fibromyalgia. Her elder sister and younger brother have no reported medical problems. Her maternal grandmother is living with dementia and her maternal grandfather has COPD.

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Social history: Elaine Goodwin is newly married. She has children from her previous relationship. she has a bachelor’s degree in accounting and is currently working as a banker. She enjoys reading novels, swimming, and riding bicycles. She takes healthy home-prepared meals. She uses seatbelts while in a vehicle and does not use a phone when driving or walking on a pathway. She denies the use of alcohol, tobacco, and other recreational drugs.

Psychiatric history: the patient denies anxiety attacks, depressive mood, post-traumatic stress disorder, and psychosis.

Violence history: the patient denies episodes of personal and public attacks, cyberbullying, and sexual harassment.

Reproductive history: her menarche was at 15 years old. She has been having a regular 28days cycle with four days of moderate flow. Her last menstrual period was on 1/6/2022. She experiences mild lower abdominal cramping and breast tenderness during her menstrual flow. she has been using coitus interruptus with her current partner. She has three children born at term via spontaneous vertex delivery. She denies post-partum complications.

Sexual history: the patient is sexually active and engages in penetrative vaginal intercourse at least three times a week. She has had three sexual partners since her first encounter at the age of 20 years. She denies a history of sexually transmitted diseases, dysuria, hematuria, vaginal discharge, post-coital bleeding, and dyspareunia.

Review Of Systems

General: the patient denies fatigue, weight loss, chills and rigors, night sweats, and fever.

HEENT: The patient denies headache, blurring of vision, loss of hearing, running nose, throat pain, and neck swelling.

Respiratory system: she denies coughing, chest pain, wheezing, sputum production, tachypnea, and difficulties in breathing.

Cardiovascular system: the patient denies palpitations, syncope, lower limb swelling, orthopnea, paroxysmal nocturnal dyspnea, and tachycardia.

Gastrointestinal system: the patient denies abdominal pain, heartburn, reflux, bloating, nausea, vomiting, constipation, diarrhea, and loss of appetite.

Genitourinary system: the patient denies dysuria, hematuria, polyuria, urgency, vaginal discharge, vaginal itchiness, and flank pain.

Neurological system: the patient denies facial droop, peripheral numbness, dizziness, muscle weakness, and changes in bowel control.

Musculoskeletal: the patient denies muscle pain, joint pain, joint stiffness, and muscle spasm.

Lymphatics: the patient denies enlarged nodes, recurring infections, and splenomegaly.

Psychiatric: the patient denies low self-esteem, insomnia, anxiety, depressive mood, and psychotic disorder.

Endocrine system: the patient denies heat and cold intolerance, weight gain, stretch marks, sweating, and irritability.

Hematologic: she denies bleeding tendencies, easy bruising, and anemia.

Skin: she denies skin color change, itchiness, and rash.

Objective Data

General examination: the patient is calm and alert. He has no pallor, jaundice, dehydration, cyanosis, edema, or lymphadenopathy.

Vitals: her blood pressure is at 118/72mmHg, her pulse rate at 68beats per minute, weight 148Ibs, weight 5’7, BMI 23.1.

HEENT: the head is round with no scars and wounds. She has no conjunctivitis, ear discharge, post nasal drip, and swollen tonsil gland.

Neck: the neck is supple with no adenopathy.

Respiratory systems: the chest wall has symmetrical expansion when breathing in. The chest wall has no mass or scars. There is a resonant percussion note and vesicular breath sounds. There is no tachypnea, rhonchi, stridor, and crackles.

Cardiovascular system: the heart is palpable at the 5th ICS. There are n parasternal heaves and thrills. The heart sounds S1 S2 is present without murmurs. The peripheral pulses are present with a regular rhythm and rate.

Abdominal examination: the abdomen is round with a normal contour, no mass, and no striae. The bowel sounds are present in the four quadrants. There is a tympanic percussion note at the abdomen. There is no shifting dullness and fluid thrills. The liver span is 1cm below the costal margin. There is no organ enlargement.

Breast examination: the breasts are soft with fibrocystic changes bilaterally, without masses, dimpling, and discharge.

Cervix: the cervix is firm, parous, and without cervical motion tenderness.

Uterus: she has retroversion of the uterus that is mobile, non-tender, and 10cm in size.

Adnexa: the adnexa has no mass, fluid accumulation, and tenderness.

VVBSU: within the normal limit but has a 1st-degree cystocele

Diagnostic Tests

  1. Complete blood count to rule out systemic infections, and check the hemoglobin levels, and platelet levels.
  2. Pregnancy test to rule out pregnancy
  3. Thyroid function test to rule out hypothyroidism and hyperthyroidism
  4. Random blood sugar to check the glycemic control
  5. Lipid profile to rule out hypercholesterolemia
  6. Breast mammogram to rule out breast cancer
  7. Erythrocytic sedimentation rate to rule out chronic diseases

Assessment

Differential Diagnoses

  1. Fibrocystic breast disease
  2. Breast cyst
  3. Fat necrosis

Fibrocystic breast disease is a benign disease of the breast that presents with a lumpy texture of the breast, tenderness, and enlargement of the nodules before menstrual periods and gets better at the beginning of a new cycle. It is common in women between 30 to 50years old. Causes are fluctuating hormonal levels, fluid fill cysts, hyperplasia of the milk duct, and enlarged breasts lobules (Kohnepoushi, et al, 2022). This is the patient’s primary diagnosis because she is above 30 years old and experiences breast pain and tenderness during her menstrual flow. On examination, her breasts are soft with fibrocystic changes and no nipple discharge.

Fat necrosis is a non-cancerous breast lump that develops in the breasts from dead or damaged breast tissue. Causes of death or damage to the breast tissues are fine needle aspiration, biopsy, breast infection, smoking, obesity, old age, chemotherapy, and breast reconstruction (Lee, et al, 2021). The presenting symptoms are firm mass or lamp, bruising of the breast tissue, nipple discharge and inversion, thickening of the breast skin, and swollen lymph nodes. This is not the actual diagnosis because the patient neither has the symptoms nor the risk factors of the disease.

A breast cyst is a benign mass of the breast that causes a breast lump. It may develop on one or both breasts causing pain and discomfort. They appear naturally at all ages but are most common after 35years old (Berg, W. A. 2021). They change due to hormonal change in size, becomes sore, and feels tender, especially during menstrual flow. The actual diagnosis is made after histopathology by fine-needle aspiration, core needle biopsy, and mammogram. This is not the diagnosis because the patient does not feel a breast lump Case Study On Gynecological Health SOAP Note Template.

Plan

Contraception Counseling

The patient is well informed of contraception methods; coitus interruptus, implant, combined oral contraceptives, and depo injection. However, these are not effective methods for her because of the side effects she has had. I would recommend she use intra-uterine devices like copper T because it does not have hormonal effects on the body. They can last up to five years with no side effects like hypertension, deep venous thrombosis, obesity, and hyperglycemia (Herrera, et al, 2019). There are no drug interactions that lowers its effectiveness, unlike hormonal contraceptives. Intra-uterine devices may cause health menstrual flow and abdominal cramping (Ouyang, et al, 2019). it does not need regular weight, blood pressure, and blood sugar monitoring. The patient can withdraw the method when the need to conceive arise. It is not associated to ectopic pregnancies and

Pharmacology Treatment

  1. Ibuprofen 400mg PO three times daily for abdominal cramping and breast tenderness.

Reflection

Assessing the patient was a good learning experience for me. Fibrocystic breast changes are common in female adults and may cause cancer most of the time. However, all women need a regular mammogram to rule out or detect malignant breast tissue. In the future, I will be equipped with more information to make an appropriate diagnosis and order investigations. Women should be aware of the benign breast changes to ensure they do self-examination and a regular check for early diagnosis and treatment.

 

References

Berg, W. A. (2021). BI-RADS 3 on screening breast ultrasound: what is it and what is the appropriate management?. Journal of Breast Imaging, 3(5), 527-538.

https://doi.org/10.1093/jbi/wbab060

Herrera, A. Y., Faude, S., Nielsen, S. E., Locke, M., & Mather, M. (2019). Effects of hormonal contraceptive phase and progestin generation on stress-induced cortisol and progesterone release. Neurobiology of stress, 10, 100151. https://doi.org/10.1016/j.ynstr.2019.100151

Kohnepoushi, P., Dehghanbanadaki, H., Mohammadzedeh, P. et al. The effect of the polycystic ovary syndrome and hypothyroidism on the risk of fibrocystic breast changes: a meta-analysis. Cancer Cell Int 22, 125 (2022). https://doi.org/10.1186/s12935-022-02547-5

Lee, J., Park, H.Y., Kim, W.W. et al. Natural course of fat necrosis after breast reconstruction: a 10-year follow-up study. BMC Cancer 21, 166 (2021). https://doi.org/10.1186/s12885-021-07881-x

Ouyang, M., Peng, K., Botfield, J. R., & McGeechan, K. (2019). Intrauterine contraceptive device training and outcomes for healthcare providers in developed countries: A systematic review. PloS one, 14(7), e0219746. https://doi.org/10.1371/journal.pone.0219746 Case Study On Gynecological Health SOAP Note Template