Nursing Assignment Help Samples for SOAP NOTES

Name:  NK

Date:  5/09/2018

Time:  11:15 Am

 Caucasian

Age:  31

Sex: Female

SUBJECTIVE

CC: 

Abdominal pain for the last 2 years occurring during the menstrual cycle

HPI: 

NK, a 31-year-old Caucasian female presents to the clinic with complaints regarding abdominal pain over the last 2 years during her menstrual cycle. She notes averting the pain through Ibuprofen and paracetamol. She further notes that the condition is a challenge since she has to take medication every month for the pain which she rates as 7 on a scale of 1-10.

Medications: Ibuprofen (400 mg two times per day) and Paracetamol (0.5 g two times per day) for the pain.     

PMH

Allergies:  Eggs and garlic

Medication Intolerances:  Patient denies

Chronic Illnesses/Major traumas:  Patient denies

Hospitalizations/Surgeries: Patient denies

Family History

NK is not married but has a fiance. Her mother has breast cancer while her father died from a grisly road accident three years ago. She has no child. She has two siblings who are older than her with two and four years. They do not have any health challenges.  

Social History

NK is a journalist in one of the local television stations. She is a Roman Catholic and devoted in social activities. She does not take any illegal substances nor alcohol. She denies smoking tobacco. She, however, hangs out with friends over the weekends. She has one sexual partner who is her fiancé. They use contraceptives although not occasionally.

ROS

General

Patient denies chills, fever, weight change, and night weights.

Cardiovascular

Denies palpitations, chest pain, edema, and PND 

Skin

Denies rashes, bleeding, discolourations, moles, or lesions. Also denies any moles or lesions. Confirms one scar on the left arm

Respiratory

Denies TB, coughing, dyspnea, pneumonia history, and hemoptysis  

Eyes

Denies corrective lenses, visual changes of any kind, and blurring

Gastrointestinal

Lower abdominal pain. Patient denies constipation, eating disorders, ulcers, and black watery stools  

Ears

Denies hearing loss, ringing in the ears, discharge, and pain.

Genitourinary/Gynecological

Patient notes abdominal pain over the last two years, especially during her menstruations. She rates the pain as 7 on a scale of 1-10. Patient denies any changes in urine colour, burning sensation during sexual intercourse, and increased frequency in urination. She further denies any history of STDs. Last pap smear and mammogram three months ago.  

Nose/Mouth/Throat

Denies nose bleeds, dysphagia, sinuses, and throat pain.  

Musculoskeletal

Denies back and joint pain. Denies history of fracture and joint swelling.

Breast

Denies bumps, lumps, and SBE.

Neurological

Denies seizures, weakness, blackout spells, and paresthesia.

Heme/Lymph/Endo

Patient confirms HIV as negative according to the last assessment four months ago. Denies bruising, history of blood transfusion, heat intolerance, hunger, and thirst.

Psychiatric

Denies anxiety, depression, sleeping challenges, suicidal ideation, and previous history.  

OBJECTIVE

Weight   145 lbs     BMI 24.9

Temp 97.9

BP  128/72

Height 5’4’’

Pulse 94

Resp 23

General Appearance

NK is a Caucasian female who is well groomed and demonstrates a high level of hygiene. She responds positively to the environment and demonstrates no acute distress. She also responds appropriately to all questions. She is however concerned about her pain and fears it might be a worse condition.

Skin

NK has a normal, smooth, warm, and dry skin. No colouration, acne or lesions. One scar on the left hand.

HEENT

Head is normocephalic and no lesions. Hair is distributed evenly. Eyes: PEERLA. No lesions cataracts, or conjunctiva. Ears: Patent canals. Pearly grey TMs. Positive light reflex. Nose: Pink nasal mucosa. The neck is supple. ROM is fill and no masses or lesions. Oral mucosa is pink and moist. No sore throat and dental caries. All teeth are intact.

Cardiovascular

S1, S2 have regular rate and rhythm. No murmurs or grits. 2 seconds capillary refill. No edema.

Respiratory

Patient denies any respiratory challenge. The chest wall is symmetrical. Regular respirations and easy. Bilaterally auscultation. Clear lungs.

Gastrointestinal

Abdominal pain of 7 on a scale of 1-10. Waist circumference normal and active BS in all quadrants. Non-tender and soft abdomen.  

Breast

No lumps, lesions, or masses in the two breasts. No skin discolouration. No discharge, wrinkling, or dimpling.

Genitourinary

Pelvic examination demonstrates a generalized suprapubic tenderness without masses. Unremarkable speculum examination. The pouch of Douglas is tender and has palpable masses. Adnexae is tender. A transvaginal ultrasound reveals bilateral endometriomas. The bladder is also non-distended, and CVA is not tender. External genitalia reveals normal distribution of the pubic hair which is also coarse. The skin colour is consistent with the general pigmentation. Cervix is nulliparous and pink.

Appropriate rectal. No haemorrhoids evidence, bleeding, masses, or fissures.  

Musculoskeletal

Normal. ROM is full in all four extremities reflected in patient mobility about the examination room.

Neurological

Normal balance and gait, clear speech, good tone and erect posture.

Psychiatric

NK is alert and oriented. She is dressed in clean and decent clothes which demonstrates high hygiene levels. She maintains direct eye contact. Her speech is clear and soft. She responds appropriately to all questions.

Lab Tests

Transvaginal ultrasound: Used to capture images inside the body to identify any abnormalities.

Pelvic examination: Important in identifying pelvis abnormalities including cysts or any scars that may be present behind the uterus.  

Special Tests

None

 Diagnosis

1.      Endometriosis

The condition is described by the tissue lining inside the uterus growing outside the uterus. It mainly involves the ovaries, pelvis tissue, and fallopian tubes. On rare occasions, the endometrial tissue can spread past the pelvic organs (Nothnick & Alali, 2016). The condition is characterised by pain which can also be severe particularly during the menstrual cycle. Other symptoms include painful intercourse, pain during urination, infertility, and excessive bleeding during the individual periods.

2.      Dysmenorrhea

These are cramping and throbbing pains in the lower abdominal region during the menstrual cycle. The pain may be severe to a level that it interferes with one’s daily activities. Common symptoms include cramping or throbbing pain during the menstrual cycle, continuous ache, and pain that may radiate in the thighs and lower back (Lacovides, Avidon, & Baker, 2015). Other symptoms include dizziness, nausea, and headache.

3.      Neoplastic Ovarian Cyst  

The condition is described as ovary sacs that are filled with fluid. Notably, most women have these cysts at a point in their lives. They are characterized by discomfort but are harmless (Singhai, Setia, Kaur, Mohan, & Bansal, 2017). While most of the cysts may disappear within weeks or months without any treatment, the raptured ones have adverse symptoms. These include pain and heaviness sensation in the lower abdomen, bloating, and fever.

Primary Diagnosis

The primary diagnosis for NK is Endometriosis which is described as a painful health condition where the tissue that lines the internal part of the uterus grows on the outside (Vercellini, Vigano, Somigliana, & Fedele, 2014). The condition is characterized by lower abdomen pain especially during the menstrual cycle which is reflected in NK situation. Besides, the transvaginal ultrasound shows the bilateral endometriomas.

Plan/Therapeutics

Plan: 

Further testing: None

Medication: OrthoTri-Cyclen (35 mcg BID daily) to suppress the condition. Patient to continue with the pain medication and especially the Ibuprofen.   

Education: Patient educated on the condition, its presentation, and management. Also educated on the importance of medication adherence and the available alternatives as treatment approaches.

Non-medication treatments: NK may consider the home management approaches including warm baths to reduce the pain and cramping. Regular exercises are also essential in improving the symptoms.

 Follow-Up

Patient to return to the clinic after two weeks to discuss the surgery option.