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PMH (include-immunization status including Gardisil, GTPLA).

PMH (include-immunization status including Gardisil, GTPLA).

PMH (include-immunization status including Gardisil, GTPLA).

SOAP NOTE

Name: J.D. Date: 03/26/2020 Time: 2:00 pm
  Age: 25 y/o Sex: F
SUBJECTIVE
CC: 

” I have a lot of pain on my left side, in my lower belly” PMH (include-immunization status including Gardisil, GTPLA).
HPI: J.D. is a 25-year-old white female that came to the office today complaining of pain in her lower abdomen. The patient has always had painful cramps with her periods but this time it is much worse being described as a 6 out of 10 and lasting up to 5 hours. The pain started 2 days ago. The pain is described as more painful cramps. It is debilitating and prevents the patient from performing most daily activities. It is localized in the lower abdominal area, and sometimes radiates down her legs, and to her lower back. The patient uses hot compresses to relieve the pain as Tylenol does not work. The patient also states that she has been feeling nauseous ever since the pain started. She also urinates more frequently and pain on urination. Denies fever, vomiting, or chills. PMH (include-immunization status including Gardisil, GTPLA).
Medications:

2 Tylenol as needed for her pain
PMH (include-immunization status including Gardisil, GTPLA).

Current or past illnesses: No current or past illnesses

Immunizations: All vaccines updated including flu vaccine and Gardasil.

Allergies: NKDA

Medication Intolerances: None.

Chronic Illnesses/Major traumas: None.

Hospitalizations/Surgeries (include delivery of pregnancies here)

No hospitalizations.

G0P0

 

 
Family History

Mother: 49 years old, no significant health problems

Maternal Side: No significant health problems

Father: 50 years old, hypertensive

Paternal Side: no significant health problems
Social History

Patient works full-time as a research assistant at a local university. A full-time student seeking a master’s degree in biochemistry at a local university. Married. Sexually active only with husband. Always uses male condoms as contraceptive device. Does not use recreational drugs, tobacco, or electronic cigarettes. Devout follower of Christianity. Denomination: catholic.

 
ROS
General Patient denies fever or chills, no weight changes. Cardiovascular Denies chest pain, or discomfort. Denies palpitations, dyspnea, or orthopnea.
Skin: Denies presences of moles, rash, or itching. Respiratory: Denies dyspnea, cough, hemoptysis, or pleuritic pains.
Eyes Denies problems or changes in her vision; denies double or blurred vision. Gastrointestinal Positive for nausea. Denies hemorrhoids, constipation, or diarrhea. No variation in bowel habits. Denies vomiting.
Ears Denies difficulty or changes in his hearing. Denies tinnitus, or discharges. Genitourinary/Gynecological Menarche 11 years old. Regular menstrual periods starting around the 3rd week of every month. LMP: 03/24/2020, heavy flow. Last pap 11/2019 -negative. No history of STDs. Male condoms used as contraceptive. Positive for lower abdominal pain. Positive for heavy menstrual flow. Positive for increased urination. Positive for pain on urination.
Nose/Mouth/Throat Denies nosebleeds, nasal obstruction. No Bleeding gums, teeth or mouth pain, no lesion in mouth or tongue, no dry mouth. Musculoskeletal Denies joint stiffness, limitation of movement, no history of musculoskeletal or disk herniation.
Breast Denies alteration of nipples, or discharge. Denies skin retractions. Denies breast pain or changes. Denies lumps. Neurological Denies syncope or seizure. No dizziness or vertigo.
Heme/Lymph/Endo Denies bruising or bleeding. No history of anemia, blood transfusions. Denies exposure to toxic agents or radiation. No HIV history. Psychiatric Denies sadness, or anxiety. No sleeping problems.
OBJECTIVE – (if you are seeing a patient for an Episodic OV – PE should relate to the CC)
Weight: 130 lb.        BMI: 21.6 Temp: 98.6 BP: 128/72
Height: 5’5’’ Pulse: 91 Resp: 20
General Appearance: Patient is alert and oriented x 4. Well-developed and nourished. She speaks clearly and appropriate. Good personal hygiene.
Skin: Intact, clean, and moist. Well hydrated, no rashes or lesions observed.
HEENT: Normocephalic, symmetric. Eyes: Sclera white, conjunctiva pink. PERRLA. Ears: Bilateral canals patent. No exudate. Nose: External aspect is normal. Lips and oral cavity pink and moist. Thyroid has a normal size, no nodules or masses noted.
Cardiovascular: S1, S2. Regular rate and rhythm, no murmurs, no gallops. No thrill or palpable murmurs on palpation. No edema.
Respiratory: Lungs clear to auscultation bilaterally anteriorly and posteriorly, normal respiratory effort. No rales, no rhonchi, no wheezes upon auscultation.
Gastrointestinal: Soft, tenderness present on deep palpation in the lower abdomen, no masses, Bowel sounds presents in all four quadrants. No ascites. No splenomegaly, no hepatomegaly. No rebound, no guarding.
Breasts symmetric: Breast tender on palpation. No discharge, no dimpling, wrinkling or discoloration of the skin; no skin retraction, no lymphadenopathy in left axilla. Both breasts with no masses or skin abnormalities. No palpable adenopathy in the either axilla.
Genitourinary: Lower abdomen tenderness on deep palpation. No CVA tenderness. Genitalia: External genitalia with pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions or masses noted. Bimanual examination: Mobile cervix, not painful. No adnexal masses or tenderness. Vaginal walls are smooth and pink; no lesions noted. Ovaries are non-palpable.
Musculoskeletal: Normal gait and ROM. No joints and muscle tenderness, no warmth, no erythema or inflammation.
Neurological: Speech normal, no sensory-perceptions disorders. No altered mental status.
Psychiatric: Alert and oriented times 4. Patient is anxious, no signs or symptoms of depression, no suicidal ideas, maintains eye contact.
Lab Tests (list the results if you have them)

CBC

Urinalysis w/culture

STD screening – Chlamydia, Gonorrhea

 
Special Tests (done or ordered during the OV)

Pelvic ultrasound

Laparoscopy

 
 Diagnosis – include the appropriate ICD – 10 Code for each diagnosis used
Primary Diagnosis:

1-Endometriosis, unspecified (N80.9). Patient has nausea, pain on urination, and unspecified tenderness in the lower abdomen. No other gynecological signs are present. Endometriosis usually does not present with any signs except tenderness sometimes (Davila, 2018). The patient is sexually active but practices safe sex with one partner.

Differential Diagnoses:

1- Torsion of ovary and ovarian pedicle (N83.51). Ovarian torsion usually has a rapid onset. This patient described the pain as beginning two days ago. It has nonspecific symptoms and is often misdiagnosed as a gastrointestinal problem (Ding, Huang, Hong, 2017). Ovarian torsion can present with abdominal tenderness on palpation. Ovarian torsion also presents with nausea in around 70% of patients (Ding, Huang, Hong, 2017).

 

2- Urinary tract infection, site not specified (N39.0): The patient reports frequent urination and pain on urination as well. UTI’s can also result in increased nausea and lower back pain (Urinary Tract Infection, n.d.)

 

3- Unspecified acute appendicitis (K35.80): Appendicitis causes onset of pain throughout the abdomen. It can cause lower abdominal pain that radiates to other areas including the lower back and legs. Additionally, appendicitis can cause nausea as well. (Appendicitis, 2019).

 

 
Plan/Therapeutics (explain fully)
Plan:

Pharmacologic: Ibuprofen 800mg three times a day.

Non-pharmacological.

-Continue using hot compresses to alleviate the pain.

If the pain worsens come back to the office or go to the nearest ER.

Follow up with patient in one week to review lab and imaging results and formulate a more specific plan of action.

Referrals:

Referral to Gynecologist.

Education:

The patient is advised to continue using hot compresses, and to take prescribed medications and to monitor the pain. Wash genital areas before and after sexual encounters to promote good hygiene and to prevent urinary tract infections. Continue safe sex practices. She is also advised to rest and to not perform any demanding activities. Increase fiber in the diet to prevent constipation.

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References

Appendicitis. (2019, March 18). Retrieved from https://medlineplus.gov/appendicitis.html

Davila, W. (2018, July 25). Endometriosis. Retrieved March 27, 2020, from https://emedicine.medscape.com/article/271899-overview

Ding, D.-C., Huang, C., & Hong, M.-K. (2017). A review of ovary torsion. Tzu Chi Medical Journal, 29(3), 143. doi: 10.4103/tcmj.tcmj_55_17

Urinary tract infection (UTI). (2019, January 30). Retrieved from https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447

 

 
 Evaluation of patient encounter:

I agreed with my preceptor that this patient has endometriosis. Her symptoms are accurate for this diagnosis. She has s/s that are characteristic of endometriosis.

 

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