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Episodic/Focused SOAP Note Template
T.S., age 58 years, female, African American
CC: “brown vaginal discharge”
HPI: T.S. is a 58-year-old married African American female, G0 P0000, seen in clinic complaining of having a brown vaginal discharge for approximately 3 days last week. The patient states that the drainage was intermittent and that the flow was mild to moderate, requiring her to change sanitary pads every 4 hours while she was experiencing the discharge. The patient described the discharge as having an “old blood” odor. She denies that she has any associated symptoms such as itching, pain, dysuria, or dyspareunia. She denies any alleviating factors.
Glipizide- 40 mg tablet po daily
Metformin- 850 mg tablet po daily
Patient denies food or environmental allergies
PMHx: Patient has a history of diabetes mellitus type 2 which is somewhat controlled with oral metformin and glipizide. Patient’s last A1C was 7.5. The patient’s pap smear history is normal; last pap was in 2020-reported an NILM, HPV negative, atrophic changes, no endocervical cells noted. Patient is UTD on annual mammogram screening. Patient had a mammogram in 5/2022 with normal results. Patient had a colonoscopy in 2021 with normal results. Patient is not due again until 2031. Immunization are UTD, including influenza and COVID. Last Tdap: 8/15/2019.
Soc & Substance Hx: Patient works as a church secretary. Patient is currently married. She currently lives with her husband and parents in a local one-story home. Patient denies ever using the following: alcohol, tobacco, or recreational drugs. She states that she utilizes seat belts when in a motor vehicle and denies texting while driving. Patient states that her current support system is her husband, parents, siblings, and church friends.
Fam Hx: Diabetes mellitus- mother, brother, sister, and maternal grandmother; high blood pressure- father, mother, brother, sister, maternal grandfather, maternal grandmother, paternal grandfather, and paternal grandmother; MI- paternal grandfather (deceased at age 62 d/t MI), maternal grandfather, and maternal uncle; CVA- paternal grandmother (deceased at age 67 d/t CVA); DVT-mother; and lung cancer- maternal grandfather (deceased at age 68 d/t lung cancer).
Laparoscopic Cholecystectomy (2015)
Bilateral breast mammoplasty (2002)
Mental Hx: Patient denies a history of anxiety, depression, or other mental history. Denies self-harm and or suicidal/homicidal ideations.
Violence Hx: Denies concerns nor issues with abuse or neglect. Patient verbalizes that she feels safe in her home and marital relationship.
Reproductive Hx: The patient has been menopausal since 2017. Patient is not taking HRT. She is G0 P0000. She attempted to conceive in the past but was unable to get pregnant. Patient acknowledges that she practices oral and vaginal intercourse. Patient was born and identifies as a woman; gender sexual preference are males. Patient denies any sexual concerns currently.
GENERAL:Denies fever, chills, body aches, recent weight gain or loss, weakness, fatigue, or night sweats.
HEENT: Eyes: Denies visual loss, blurred vision, or double vision. HEAD, Ears, Nose, Throat: Negative for headaches, ear pain or drainage; nasal discharge or postnasal drip. Denies sore throat or cough.
SKIN: Denies bruises, rashes, or itching. Denies any visible changes to existing lesions or moles.
BREAST: Denies breast tenderness, erythema, inflammation, or nipple discharge.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort, palpitations, or edema.
RESPIRATORY: Denies shortness of breath, wheezing, or cough.
GASTROINTESTINAL: Denies abdominal pain, heartburn, nausea, vomiting, or anorexia. Denies diarrhea, constipation, or bloody stools.
NEUROLOGICAL: Denies having any recent falls, contributory traumas, unsteady gait, headaches, dizziness, slurred speech, muscular weakness, numbness, tingling, or syncope. Denies slurred speech.
MUSCULOSKELETAL: Denies muscle, back pain, neck pain, joint pain, or stiffness.
HEMATOLOGIC: Denies anemia, bleeding, or bruising.
LYMPHATICS: Denies enlarged nodes.
PSYCHIATRIC: Denies any visual or auditory hallucinations, suicidal thoughts or ideations, anxiety, depression, or insomnia.
ENDOCRINOLOGIC: Denies problems with heat or cold intolerance.
GENITOURINARY/REPRODUCTIVE: Positive for brown vaginal discharge. Denies vaginal pruritus or burning. Denies urinary frequency, dysuria or hematuria.
ALLERGIES: Denies asthma, hives, eczema, or rhinitis.
VS: BP 140/88 sitting; P 82; R 12; T 98.1; Height 5’6”; Weight 272 lbs (BMI 43.90)
GENERAL: well-nourished, well-developed, alert, and in no acute distress.
HEENT: normal appearance, no masses or tenderness noted. Thyroid gland is of normal size, nontender, nodules or masses absent on palpation.
SKIN: No rashes, lesions, or areas of discoloration noted. No abnormalities or tenderness noted on palpitation.
BREAST: No tenderness noted upon palpation. No erythema, inflammation, or nipple discharge noted.
CARDIOVASCULAR: Regular rate & rhythm, normal S1/S2. No gallops. No murmurs.
RESPIRATORY: Lungs clear to auscultation bilaterally. No wheezes nor rhonchi noted. Normal respiratory effort.
GASTROINTESTINAL: Abdomen soft, obese, and nontender to palpation. Normal bowel sounds x 4 quadrants auscultated. No hepatomegaly present; liver nontender to palpation. No hernias present.
NEUROLOGICAL: awake, alert, oriented to person, place, time, and situation. Reflexes grossly intact. Speech: normal. Gait: normal.
LYMPHATICS: no lymphadenopathy present.
PSYCHIATRIC: calm and cooperative. Mental status grossly normal. Appearance grossly normal. Normal mood and normal affect.
External Genitalia: brown discharge noted. Normal appearance for age; negative vulvar erythema; no tenderness present; no inflammatory lesions present; no rashes present; no hypopigmentation noted.
Urethra: no abnormalities noted.
Vagina: atrophic changes noted. A thin, brown discharge noted. Adequate support. No inflammatory lesions or masses present.
Cervix: brown blood noted coming from os. Normal healthy appearance; no lesions present; no cervical motion tenderness; no bleeding present.
Uterus: Unable to assess due to body habitus.
Adnexa: Unable to assess due to body habitus.
Vaginal ultrasound- Transvaginal ultrasound is usually the initial diagnostic test in the work-up for postmenopausal bleeding. Ultrasound specifically finds thickened endometrium, endometrial fluid, or abnormal vascularity, which are associated with an increased risk of endometrial cancer (Long et al., 2020). In a woman in the early stages of menopause, an endometrial thickness of >11 should prompt an endometrial biopsy (Deenadayal, 2021).
Primary and Differential Diagnoses
Endometrial hyperplasia- Endometrial hyperplasia is a pre-cancerous, abnormal thickening of the uterine lining. Research studies have found that factors such as female age, nulliparity, hormone replacement therapy use, estradiol levels, anovulatory cycles and obesity are considered important elements affecting the growth of the endometrium and predispose to endometrial hyperplasia (Aldarazi et al., 2022). In this patient’s case, this is the primary diagnosis due to the patient’s obesity, age, and nulliparity.
Endometrial polyp- Endometrial polyps are principal central intrauterine endometrial neoplasms that may be single or multiple in numbers. Their size may vary from a few millimeters to several centimeters, and their morphology may be without a stalk or pedunculated, with a large or small implantation base. Known risk factors for the development of endometrial polyps are progressive age, hypertension, obesity, and tamoxifen usage. Endometrial polyps may be asymptomatic or cause abnormal, postmenopausal uterine bleeding and infertility (Vitale et al., 2021).
Endometrial carcinoma- Endometrial cancer is the most common malignancy of the female genital tract in developed countries. Pelvic ultrasound and endometrial biopsy taken by Pipelle, dilatation and curettage (D&C) or hysteroscopy are the standard methods for diagnosis, allowing the disease to be diagnosed in early stages. The preferred treatment is a surgical total hysterectomy (TH) and bilateral salpingo-oophorectomy (BSO), which continues to be the basis for treatment of low grade EC. Lymph node dissection remains controversial and is not advised. Endometrial cancer patients have a very low chance of lymph node metastasis, therefore pelvic and para-aortic lymphadenectomy for these patients have no advantage (Laban et al., 2021).
Refer patient to OBGYN physician for endometrial biopsy, Dilation and Curettage (D & C), possible hysteroscopy to assess endometrium.
Have patient follow-up with primary care physician for glucose control.
Have patient return to clinic in one year for annual exam or sooner if problems persist or worsen.
Educate patient on importance of weight loss, daily exercise (4-5 days/week for 30 minutes each day) and following an appropriate diabetic diet to assist with glucose levels.
In reflection of this case study, I have acquired additional knowledge regarding postmenopausal bleeding. The assessment, diagnostic testing, differential diagnoses, and various treatment plans were researched and are cognizant to me now. In this case, the patient’s obesity, menopausal state, nulliparity, and diabetes placed the patient at a high risk for endometrial cancer, factors that I was not familiar with before this assignment.
Aldarazi, K., Omran, H., & Jassim, N. M. (2022). Endometrial hyperplasia in asymptomatic subfertile population. Journal of Gynecology Obstetrics and Human Reproduction, 51(4), 102337. https://doi.org/10.1016/j.jogoh.2022.102337.
Deenadayal, M. (2021). Understanding the endometrium at Menopause: A Sonologist’s view. Journal of Mid-Life Health, 12(1), 66. https://doi.org/10.4103/0976-7800.313985.
Laban, M., Nassar, S., Elsayed, J., & Hassanin, A. S. (2021). Correlation between pre-operative diagnosis and final pathological diagnosis of endometrial malignancies; impact on primary surgical treatment. European Journal of Obstetrics & Gynecology and Reproductive Biology, 263, 100–105. https://doi.org/10.1016/j.ejogrb.2021.06.008.
Long, B., Clarke, M. A., Morillo, A. D., Wentzensen, N., & Bakkum-Gamez, J. N. (2020). Ultrasound detection of endometrial cancer in women with postmenopausal bleeding: Systematic review and meta-analysis. Gynecologic Oncology, 157(3), 624–633. https://doi.org/10.1016/j.ygyno.2020.01.032.
Vitale, S. G., Haimovich, S., Laganà, A. S., Alonso, L., Di Spiezio Sardo, A., & Carugno, J. (2021). Endometrial polyps. an evidence-based diagnosis and Management Guide. European Journal of Obstetrics & Gynecology and Reproductive Biology, 26
P.H., 29-year-old, Female
CC: “Positive home pregnancy test”
HPI: G6 T2 P1 A2 L 4, 7wks 6days is here today after a positive home pregnancy test with c/o breast tenderness, fatigue, and nausea. This led her to think that she could possibly be pregnant.
Current Medications: Woman’s gummy vitamin, 1 gummy PO daily x 12 months
Soc. & Substance Hx: Negative for alcohol, tobacco, and illegal substances. Has a male partner, who’s she has been with for 3 years.
Fam Hx: Mother-alive, DM2, age 50. Father-alive healthy, age 52. Sibling- brother- alive, healthy age 26. Children- (2) Sons-age 8, alive, healthy and age 5 alive, healthy. (2) daughters- age 6 alive, healthy.
Surgical Hx: None
Mental Hx: None
Violence Hx: None
Reproductive Hx: Menarche at age 12, cycle q28 days, lasting for 5 days. No Hx of abnormal pap smears, STD Hx negative. Hx of 2 NSVD, Hx of 1 delivery w/low forceps, Hx of 1 spontaneous abortion, Hx of 1 terminated abortion. Hx of gestational diabetes during 2nd and 5th pregnancies. Sexually active with men only. LMP 8/25/22.
GENERAL: C/o fatigue. No weight loss, fever, chills, weakness.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: Positive for nausea. No anorexia, vomiting, or diarrhea. No abdominal pain or blood.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.
GENITOURINARY/REPRODUCTIVE: No change in urinary regimen. Positive home pregnancy test. LMP: 08/25/2022. C/o breast tenderness. No reports of vaginal discharge or pain. Sexually active with men only.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
Vitals: Height-62.5in, Weight- 153lbs, BMI-27.5, BP- 122/80 mmHg, HR-84bpm, RR-18/min, T-98.6.
General: Alert and Oriented x4. Well nourished, well hydrated, in no acute distress, cooperative with exam.
Cardiology: Regular rate and rhythm, no murmurs. No peripheral edema.
Respiratory: Clear in all lobes bilaterally upon auscultation.
Abdomen: Non-distended. Non-tender to palpation. Bowel sounds present in all quadrants.
Genitourinary/Reproductive: Confirmed pregnancy. LMP-8/25/22.
Psych: No s/s of depression, no suicidal thoughts or ideation.
Diagnostic Results: HCG with positive results- According to Betz and Fane, (2022), measuring HCG levels help to identify normal pregnancies, abnormal pregnancies such as ectopic or molar pregnancies, and possible miscarriages.
N91.2 -Amenorrhea- The patient’s LMP was on 8/25/2022. The patient states a prior history of regular periods occurring q 28 days. According to Nawaz and Rogol, (2022), pregnancy and lactation are the most common states of amenorrhea.
R11.0- Nausea- The patient states having nausea along with other symptoms of pregnancy. According to Gadsby et al, (2021), the onset of nausea and vomiting can be used to determine a range for dating of pregnancy from the LMP and ovulation.
Z32 Pregnancy Test, unconfirmed-The patient states taking a pregnancy test at home. Results to be confirmed in office. According to Betz and Fane, (2022), urine assays for detecting HCG levels is more sensitive than over the counter tests.
Additional Tests: Dating ultrasound ordered to complete in one week.
Therapeutic Interventions: Patient to start Prenatal 28- 0.8mg tabs, 1 tab PO daily x 60 days.
-Patient educated that during pregnancy the hormonal changes that her body is going through can trigger symptoms such as breast tenderness, nausea, vomiting especially in the morning, fatigue, changes in appetite, mood swings, increase in the frequency of urination, constipation, weight gain or loss, headache, and heartburn (Office on Women’s Health, 2022).
-Patient educated to eat meals and snacks in small quantities q 1 to 2 hours to prevent nausea (Smith et al., 2022).
– Patient educated on living a healthy lifestyle but eating healthy, increasing fluids, not smoking or drinking alcohol, and limiting sodas and sweet drinks.
-Patient educated about the importance of taking daily prenatal vitamins for the health of the baby’s growth and development.
-Patient educated about the importance of attending prenatal visits for proper prenatal care.
-The patient given the website babycenter.com to stay informed on the weekly growth of her baby and other supportive tips.
Disposition of the Patient: Patient is happy, excited about the positive pregnancy results.
Follow- up Visits: Patient to f/u with the office in 2 weeks for OB intake.
As a provider it is important to educate newly pregnant patients with what to expect in the upcoming weeks of their pregnancy. A provider also has an obligation to educate the patient about her choices with her pregnancy. If her choice is to continue the pregnancy, then as a provider I will offer supportive services and resources to aid the woman through post-partum. If the patient desires to abort the pregnancy, then I as a provider have an obligation to educate the patient on safe practices to abortion within my states laws and to provide support services and resources. I will remain a neutral party and give informed care throughout which ever path my patient chooses.
Betz, D., Fane, K. (2022). Human Chorionic Gonadotropin.
Gadsby, R., Ivanova, D., Trevelyan, E., Hutton, J., & Johnson, S. (2021). The onset of nausea
and vomiting of pregnancy: a prospective cohort study. BMC Pregnancy Childbirth 21,
Nawaz, G., Rogol, A.D. (2022). Amenorrhea. https://www.ncbi.nlm.nih.gov/books/NBK482168/
Office on Women’s Health. (2022). Stages of pregnancy.
Smith, J., Fox, K., Clark, S. (2022). Nausea and vomiting of pregnancy: treatment and outcomes.
Patients%20with,can%20aggravate%20nausea%20%5B2%5D.0, 70–77. https://doi.org/10.1016/j.ejogrb.2021.03.017.
Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning. Chapter 17, “Breast Conditions” (pp. 337-349)Chapter 32, “Anatomy and Physiologic Adaptations of Normal Pregnancy” (pp. 677–673)Chapter 19, “Pregnancy Diagnosis, Decision-Making support, and Resolution” (pp. 367-379)
General Guidelines for Health Screenings
American Academy of Family Practice (AAFP). (2020). Browse AAFP clinical recommendations. https://www.aafp.org/home.html
American Cancer Society, Inc. (ACS). (2020). Cancer A-Z. https://www.cancer.org/Note: As you review this resource, select the “Cancer A-Z” topic in the navigation to review information and Resources about for Cancer: Breast, Colon, Lung, Prostate, Skin.
American College of Obstetricians and Gynecologists (ACOG). (2020). Clinical topics. https://www.acog.org/Note: As you review this source, make sure to navigate to the “Topics” section in the navigation to review the clinical topics.
HealthyPeople 2030. (2020). Healthy People 2030 Framework. https://www.healthypeople.gov/2020/About-Healthy-P…
U.S. Preventive Services Task Force (USPTFS). (2017, September). Search and Filter All Recommendation Topics. https://www.uspreventiveservicestaskforce.org/usps…
Centers for Disease Control and Prevention. (CDC). (n.d.). Disease & conditions. https://www.cdc.gov/DiseasesConditions/
The American Association of Nurse Practitioners (AANP). (2020). AANP practice: Clinical Resources, Business, acumen and opportunities for professional recognition. https://www.aanp.org/practice
Nicholas, J. A., & Hall, W. J. (2011). Screening and preventive services for older adults. The Mount Sinai Journal of Medicine, New York, 78(4), 498–508. https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1002/msj.20275
Document: Focused SOAP Note Template (Word document)
Document: General Guidelines for Health Screenings Matrix Template (Word document)
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