Sample - Soap Note for Anteverted Uterus

Nursing Assignment Help and Essay Writing Sample for Soap Notes - Anteverted Uterus

Name: CW

Date: 16/10/2018 Time:  10:50 Am Hispanic 

Age: 30 Sex: Female

SUBJECTIVE

CC: 

Annual exam  

HPI: 

CW, a 30-year-old Hispanic female presents to the clinic for an annual examination. She notes regular menses with no intermenstrual bleeding. She uses IUD contraception since the birth of her last child I year ago. She denies any issue with the IUD method.

Medications: Patient denies

PMH

Allergies:  NKDA Medication Intolerances: Patient denies

Chronic Illnesses/Major traumas:  Patient denies

Hospitalizations/Surgeries: Caesarian Section for the last child.  

Family History

CW is a Hispanic female with two children. She has been married for 10 years. She gave birth to her second child last year. She is in a monogamous relationship with her husband who has no health condition. Both her children who are male and female are healthy. Mother is alive but suffers from hypertension. Her father died at the age of 67 from prostate cancer. She has two siblings who are both healthy.    

Social History

CW is a Christian and attends church regularly. She is however not denominational but is involved in community services. The patient is a banker. She has been in a monogamous relationship for the last 10 years. She leads a healthy life where she exercises twice a week. She does not smoke nor abuse illegal drugs.

ROS

General

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

Cardiovascular

Patient denies orthopnea, edema, and chest pains. 

Skin

Patient 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

The patient wears specs for correcting short-sightedness. Denies any blurring or visual changes.

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 any issues with urination such as burning sensation, changes in colour, and urgency. She uses IUD contraception but notes no effect. She is sexually active and has no STD history. Last pap smear one year ago. No abnormal paps noted. Positive BSE. Denies vaginal discharge. Two pregnancies and two deliveries.

Nose/Mouth/Throat

Patient denies any sinuses problems, nose bleeding, dental caries, and teeth breakages. No throat pain also  

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

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

Psychiatric

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

OBJECTIVE

Weight   161 lbs    BMI 26.0 Temp 97.8 BP 128/74

Height 5’6’’ Pulse 94 Resp 23

General Appearance

CW appears healthy and in no acute distress. She is oriented and alert. She responds to all questions appropriately. She is well groomed which reflects on high hygiene levels.  

Skin

Skin is normal, 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.

Cardiovascular

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

Respiratory

No respiratory issues reported. The chest wall is symmetric. Respirations are easy and regular. Lungs are bilaterally clear to auscultation.  

Gastrointestinal

Slightly overweight but abdominal tests are normal. The abdomen is non-tender and soft. No hepatosplenomegaly.   

Breast

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

Genitourinary

Non-distended bladder. No CVA tenderness. External genitalia 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 is multiparous. No lesions noted. Bimanual: Small uterus, anteverted, NT, no tenderness or adnexal masses.

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 balance and gait.  

Psychiatric

CW 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

Cervical exam

Pap Smear 

Special Tests

None

 Diagnosis

1.     Anteverted Uterus

This entails the uterus being tilted forward. Notably, the uterus is dislocated towards the bladder. It is a common issue among women and especially among those with complexities during their pregnancies. It is caused by various aspects including birth defects and caesarean delivery (Zhang, He, Huang, & He, 2016). Common symptoms include abdominal pain during menstruation, constipation prior to menstruation, foul smelling, and ovarian pain during ovulation.

2.     Uterus Abnormality: Small

This describes a uterus that does not conform to the normal characteristics. It is different based on size and shape. For a small uterus, main symptoms include painful intercourse, increased urination, menstrual cramping, and pain in the lower back and pelvis (Demain et al., 2017).

3.     Uterine Fibroids

These are noncancerous growths of the uterus which present during the childbearing period. They result in bulky masses and can enlarge or distort the uterus. They are characterized by pelvic pain, constipation, leg pains, menstrual periods for more than a week and heavy menstrual (Donnez et al., 2015).

Primary Diagnosis

From the exam, CW has a small and anteverted uterus which in broad explains abnormality. This is described as a uterus that does not demonstrate normal characteristics. No apparent symptoms associated with the situation presently.     

Plan/Therapeutics

Plan: 

Further testing: None

Medication: Visit the clinic for hormonal evaluation in case she needs to get pregnant again due to the abnormal uterus.   

Education: Continue practising healthy behaviours including exercises and diet. Completely avoid any illegal drugs and alcohol. Patient should be educated on maintaining a normal body weight.    

Non-medication treatments: Lifestyle modification such as food and exercises to lead a healthy life.    

 Follow-Up

Return to the clinic after one year or in case of any health challenges.  

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