Nursing Assignment Help Samples - SOAP NOTES

Name:  DK

Date:  24/09/2018

Time:  08:16 Am

 African American   

Age:  33

Sex: Female

SUBJECTIVE

CC: 

Follow-up for the left-sided pelvic pain.

HPI: 

DK, a 33-year-old African American returns to the clinic for follow-up on the chronic left sided pelvic pain. The patient was first seen 3 months ago. She describes the pain as dull and aching, intermittent and has no relationship to eating. However, the pain increased before and after menses. The pain has been worse over the last few months

Medications: Patient denies NSAIDs

PMH

Allergies:  Patient Denies

Medication Intolerances:  Patient denies

Chronic Illnesses/Major traumas:  History of Chlamydia which was managed through medication.

Hospitalizations/Surgeries: Patient denies

Family History

DK is an African American female with G3P1. She has multiple partners. Her child is healthy. Both her parents are alive. Mother has Diabetes Mellitus Type II while the father has Meningitis.      

Social History

DK is a Christian but rarely attends church. She is dormant on social activities. She works at a nearby fast foods restaurant. She takes alcohol but no illegal drugs. She has a college education.

ROS

General

Patient denies changes on weight change, fever, chills, energy levels, night sweats, and fatigue.  

Cardiovascular

Patient denies orthopnea, edema, and chest pains. 

Skin

Denies any delayed healing, bruising, skin discolouration, rashes, and changes in moles or lesions.

Respiratory

Patient notes no wheezing, dyspnea, pneumonia, and TB history.   

Eyes

Patient denies any corrective lenses, visual changes, and blurring.  

Gastrointestinal

Denies constipation, abdominal pain, haemorrhoids, eating challenges, ulcers, and black, tarry stools.

Ears

Patient denies any hearing loss, ringing in the years, and discharge.  

Genitourinary/Gynecological

Patient denies burning sensation during urination, changes in colour, and frequency. She uses birth control pills as contraceptives. She is sexually active and has Chlamydia history.

Nose/Mouth/Throat

Patient denies any sinuses problems, nose bleeding, dental caries, and teeth breakages. Denies sore throat  

Musculoskeletal

Patient denies any joint swelling, history of fracture, back pain, and osteoporosis.  

Breast

Positive SBE. Denies any breast bumps, lumps, and lesions.  

Neurological

Patient denies any seizures, weakness, black-out spells, and transient paralysis.  

Heme/Lymph/Endo

Patient notes HIV status as negative, no history of blood transfusion, night sweats, swollen glands, increased hunger, thirst or heat intolerance.

Psychiatric

Patient denies anxiety, insomnia, suicidal ideation, and depression.   

OBJECTIVE

Weight   158 lbs     BMI 24.7

Temp 98.1

BP  130/72

Height 5’7’’

Pulse 93

Resp 24

General Appearance

DK is a healthy appearing adult female. She demonstrates no acute distress. She is alert and oriented. She responds to questions appropriately.   

Skin

Skin is even, warm, smooth, and intact. There are no lesions or rashes noted.  

HEENT

Head is atraumatic, normocephalic and has no lesions. The hair is evenly distributed. Eyes are responsive to light and pupils are similar. EOMs are intact. There is no scleral injection or injected conjunctiva. Ears: Patent canals, bilateral TMs pearly gray with positive light reflex. Easily visualized landmarks. Nose: pink nasal mucosa, normal turbinates. There is no septal deviation. The neck is supple. Full ROM: no cervical lymphadenopathy. No occipital nodes. No nodules nor thyromegaly. Oral mucosa is moist and pink. Pharynx nonerythematous and no exudate. Teeth are in good repair and are all intact

Cardiovascular

S1, S2 with regular rhythm and rate. No murmurs, rubs, and clicks. Capillary refill 2 seconds. Pulses 3+ throughout and no oedema.   

Respiratory

The chest wall is symmetric. Respirations are easy and regular. Lungs are bilaterally clear to auscultation.  

Gastrointestinal

Normal weight and abdominal tests. No constipation, nausea, vomiting, and diarrhoea.    

Breast

No lesions or masses, tenderness, dimpling, wrinkling, and discharge. No skin discolouration.

Genitourinary

Non-distended bladder. No CVA tenderness. External genitalia: Normal and shows coarse pubic hair which is normally distributed. Consistent skin colour. General pigmentation. No noticeable vulvar lesions. Vaginal walls are pink, moist, and well rugated. Cervix: No lesions noted. Bimanual: Small uterus, anteverted, NT, 3+ left adnexal tenderness. No right adnexal tenderness. No massess palpated.  No vaginal discharge.

Musculoskeletal

Full ROM in all the four extremities as the patient moves about in the exam room.  

Neurological

Speech is clear with good tone. Erect posture. Stable gait and balance  

Psychiatric

DK is oriented and alert. She demonstrates high hygiene levels. Maintains eye contact. The speech is soft, clear, and has a normal rate. She responds to questions appropriately.  

Lab Tests

Pelvic exam  

Special Tests

None

 Diagnosis

1.      Endometriosis

The condition is characterised by tissue that lines the uterus growing outside of it. It can also affect the fallopian tubes, ovaries, bladder, and other body parts. It is characterised by dysmenorrhea, painful intercourse, painful urination, excessive bleeding, and infertility (Vercellini, Vigano, Somigliana, & Fedele, 2014).

2.      Mittelschmerz

The condition is described by one-sided lower abdominal pain and is related to ovulation. It is characterized by dull and cramp-like pain that is sharp and sudden, mild vaginal bleeding, and pain on one side of the lower abdomen (Kumar, 2018).

3.      Menstrual Cramps

These are cramping pains in the lower abdomen which occur before and during the menstrual period. The condition is characterized by dull and persistent ache, cramping pain on the lower abdominal region, nausea, and headache (Davis, 2018).

4.      STI

Common STDs resulting in lower abdominal pain are Gonorrhea and Chlamydia. Symptoms include painful urination, lower abdominal pain, painful sexual intercourse, and vaginal discharge (Fernandez-Romero et al., 2015).

5.      Pelvic Inflammatory Disease

The condition is described as an infection of the reproductive organs. It occurs after an STI bacteria spreads to the uterus, ovaries, and fallopian tubes from the vagina. Symptoms include painful intercourse, painful urination, painful discharge, and lower abdominal pain (Brunham, Gottlieb, & Paayonen, 2015).

Primary Diagnosis

Based on the symptoms and examination, the primary diagnosis is the menstrual cramps. This is centred on the nature of the pain and its occurrence. These include the cramping pain which is intense that occurs before and during the menstruation period. The pain is also continuous and dull.      

Plan/Therapeutics

Plan: 

Further testing: Diagnostic Laparoscopy  

Medication: Ibuprofen (400 mg) three times a day for lowering the pain.     

Education: Education on home remedies and lifestyle management including reducing stress and exercising regularly. The patient should maintain a healthy diet.      

Non-medication treatments: Dietary supplements and a hot bath. Lifestyle change including exercises and a healthy diet.

 Follow-Up

Return to the clinic after a week for the laparoscopy diagnostic results and consider other possible diagnoses and approaches