NUR 514 STU SOAP note for Endometriosis Women Health

Create a focused SOAP note to support (only include positive and pertinent data) for a 40-year-old female patient with the diagnosis of Endometriosis.

• Discuss and described the pathophysiology and symptomology/clinical manifestations of Endometriosis.
• Discuss three differential diagnoses for AUB with ICD 10 numbers for each.
• Discuss patient education
• Develop the management plan (pharmacological and nonpharmacological).

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1 Soap Note Estefania Batallas St. Thomas University 3/28/2021 2 SOAP NOTE Encounter date: 03/24/2021 Subjective Data Patient Initials: K.J. Age: 28 years Race: Hispanic Gender: Female Chief Complaint: “I have been feeling pain, bloating of my abdomen for the past two days.” History of the Present Illness (HPI): 28-year-old female was well until two days when she began experiencing severe abdominal, which she described as severe and sharp knife-like pain. The pain is localized to the lower abdomen but intense on the right side. The pain is worse on movement but slightly relieved by Advil. The pain is of gradual onset and worsened in the last one day. The severity woke her up twice the previous evening. She reports associated chills and sweat after taking Advil. She is sexually active with a new partner for four months. Her previous relationship ended a year ago. They don’t use protection regularly. Her LMP was 20 days ago, approximately 03/1/2021. She had a little yellowish vaginal discharge for 11 days ago but assumed it was yeast. She took OTC medication (Gyn-Lotrimin). The release was persistent but ignored because it was not much. No history of burning sensation, pruritus, or vulval swelling. She denies frequency, dysuria, or urgency. G1P0, one elective four years ago NUR 514 STU SOAP note for Endometriosis Women Health.

Menarche at the age of 14 years, regular cycle 28 days, and flow 4-6 days. She never initiated a series of hepatitis. No history of HTN, Diabetes, asthma, or cancer. Previous injuries, accidents, and hospitalization: non-contributory. Allergies: K.J. denied having allergies associated with latex, environmental elements, food, and drugs. Current Perception of Health: Past Medical History • • • • • • • • • • • • • Chronic Disease: No Inpatient: No Allergies: No Currently on medicine: No Immunizations: Compliant Flu Shot: given 10/2020 Cancer: No Heart Disease: No Diabetes: No Hypertension: No Stroke: No Depression: No Alcoholism: No Excellent Good Fair Poor 3 Previous Surgery: The patient reports that she has never been operated on. Medication: The patient reports that she is not on any medication Family History: The patient reports that her father is alive, with history of chronic ulcers, currently medicated, aged 42 years, and mother is also alive and healthy aged 39 years. She is the second-born in a family five with both of her other siblings being healthy males. Personal/Social History: Lifestyle: K.J. reports that she lives with her parents and siblings in a city apartment. Marital status: The patient is single Occupation: College Student Education: Currently completing her bachelor’s degree. Religion: Catholic Tabacco: Denied used of tobacco ETOH/Drugs: Denies alcohol and illicit drug. Sexual orientation: The patient reports that she is heterosexual, active sexual activity. She denies use of contraception. Onset of coitus age 19, 1 partner. Screening Tests: K.J. has annual eye exams and dental exam every 6 months. K.J. has wellness check-ups as recommended by FNP. PSC-17- Score = 9 no action needed. PHQ-9 – Score = 4 no action needed. Immunization History: The patient reports that she received all childhood immunizations and an additional yellow fever immunization in 2019 when she travelled with her parents abroad. Safety: K.J. reports that she always takes all safety precautions like wearing seat belts, avoiding bad company, and taking drugs as prescribed by her doctors and guided by her parents. PMH: Menstrual history: LMP: 3/1/2021, menstruation started at age 14. OB history: G1P0 Last pap smear: 3/01/2020 Last MMG: Does not apply. 4 Review of Systems (ROS) General Review: Admits to constant severe and sharp knife-like stomach pain. She denies weakness, fatigue, cough, and dysuria. Eyes: Admits to using glasses when at school and home when reading. Last year’s examination was in 2020, normal.

Denies eye pain, poor eyesight, and vision changes. Ears: Denies drainage, hearing loss, popping, fullness, and pain. Nose: Denies sinus pressure, loss of smell, allergies, bloody, and drainage. Mouth: Denies gingivitis, ulceration, and bad breath Throat: Denies throat pain, hoarseness, or dysphagia. Lungs: Denies wheezing and cough. Breast: Denies nipple changes, bumps, and lumps. Cardiovascular/Peripheral Vascular: Denies, syncope, claudication, ankle edema, Denies cardiac arrhythmia, heart murmur, heart disease, MI, chest pain or palpitations Neuro: Denies headache, numbness/tingling in extremities, loss of consciousness HEME: Denies bleeding disorders, blood transfusions, and anemia G.I.: admits of anorexia, diarrhoea, and vomiting. Denies dysphagia, reflux, indigestion, and constipation. GU: Denies frequency, urgency, hesitancy, change in color or odor, hematuria, vaginal discharge or lesions, dyspareunia Female genital: Denies itching and bleeding. Musculoskeletal: Denies ever feeling back pains, trauma, or stiffness Psychologic: Denies any mood changes nor any other mental disorders. Integumentary: The patient has not seen any changes in her nails, hair, or skin. Endocrine: Denies polydipsia, polyuria, and polyphagia, intolerance to heat or cold. Allergies: Denies having any allergic conditions Nutrition: Admits to always taking a balanced diet through the guidance of her parents Sleep/Rest: The patient reports that she sleeps for at least eight hours every day OBJECTIVE DATA Physical Examination Signs: Pulse, 72 / Temp. 98.2F / Resp., 15/ Pulse Ox 98%PO2/ BP 120/90 Height: 5.3” Weight: 142 lbs. BMI 25.2 General Appearance: She is ill-appearing and in pain. HEENT: Negative 5 Neck: Supple. Chest: Clear. Heart: regular with no murmur. Abdomen: Bowel resonance hypoactive with right lower quadrant tenderness and guarding. Genitalia: is normal with no hernias. Rectal: No tenderness or masses. The slow walking pace and slightly arched. General: Healthy appearing female, developmental process is good, in no acute distress. Alert and Oriented. HEENT: Head is normocephalic, atraumatic and without lesions; hair evenly distributed. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Trachea midline. Thyroid midline, equally rises and falls, no enlargement, asymmetry, masses, nodules or tenderness appreciated on palpation. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Dentition is good. Pulmonary: Symmetric chest wall. CTA B/L, no wheezes, rhonchi, rales on auscultation. Cardiovascular: The S1 and S2 are at a regular rate and rhythm. There are no murmurs heard, clicks or any kind of extra sounds. The rate of capillary refill is 2 seconds. The femoral pulses maintain at 2+ with no cases of edema. Breast: Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin, normal as per her age. GI: Abdomen flat. BS active in all 4 quadrants. Abdomen soft, non-tender NUR 514 STU SOAP note for Endometriosis Women Health.

No hepatosplenomegaly. No rebound tenderness or guarding noted during deep palpation. Female genital: Rugate pink vaginal walls, no lesions, no discharge or blood, strong muscular tone. Pelvic Exam: normal external genitalia, but speculum shows yellow purulent discharge from the cervical os. The bimanual examination elicits cervical motion tenderness and a right adnexal mass. The uterus is retroflexed and of standard size GU: Bladder is non-distended; no CVA tenderness. Skin is in unison with the entire pigmentation. Neuro: AAOx3, pleasant affect. Musculoskeletal: Full ROM seen in all 4 extremities as patient moved about the exam room. Muscle strength 5/5 in all extremities. No scoliosis, and no lordosis noted. No muscle spasms noted. Muscle atrophy noted to thighs and calves. Derm: Skin is pink, warm, and dry. No diaphoresis noted. No lesion or moles noted. Psychosocial: Alert and oriented within the due course of the process. 6 Differential Diagnosis 1. Urinary tract infection unspecified (N39.0). This was suspected especially by the fact that the patient had lower abdominal pain. With urinary tract infection, one would have dysuria, frequency, urgency and at times hematuria. The dip stick urinalysis will indicate presence of nitrites and leucocytes in the urine and urine culture results will be positive for bacterial growth. The whiff test will be positive for nitrites. The most common organism causing UTI is E.Coli (Symonds et al, 2013). 2. Vaginal candidiasis (B37.3). This is a fungal infection caused by candida albicans. When it affects the vulva or vagina, it causes itchiness in these regions and watery discharge. It is common in the diabetic and immunosuppressed patients. Treatment is by provision of antifungal drugs (Symonds et al, 2013). 3. Trichomonal vulvovaginitis (A59.01): this is a sexually transmitted infection caused by trichomonas vaginalis. The signs and symptoms include copious greenishyellowish per vaginal discharge which has a fishy smell and vulvo-vaginal itchiness (Symonds et al, 2013). Primary Diagnosis: 1. Neisseria Gonorrhea infection of lower genital tract unspecified (A54.30)NUR 514 STU SOAP note for Endometriosis Women Health. It is a sexually transmitted disease that causes gonococcal urethritis in males and cervicitis in females. Ascent of the bacteria to the fallopian tubes will lead to pelvic inflammatory disease which could lead to secondary infertility.

The bacteria are seen under the microscope as gram negative diplococci. This was ruled out by a negative gonococcal test (Symonds et al, 2013). 7 Impression Pelvic inflammatory disease possibly due to chlamydia trachomatis infection or Neisseria gonorrhoeae. Laboratory tests • • • • • • • • Dip stick urinalysis: normal results Whiff test: Negative for amines Urinary pregnancy test : negative HIV test : negative Chlamydia testing : negative Gonorrhea testing : positive VDRL : negative Pap smear : normal Pending results for: • • • • Complete blood count Herpes simplex virus antibody screen Urinalysis and culture HPV testing Special tests • • • Microscopy, culture and sensitivity for the lymph node aspirates Culdocentesis High vaginal swab. Radiological tests • Pelvic ultrasound: free fluid in the fallopian tubes and the pouch of douglas. Features suggestive of PID Plan / Pharmacological Therapy: The goal of treatment is to prevent adverse reproductive health complications and continued sexual transmission and treating the sexual partners to prevent reinfection and infection of other partners. Pharmacological therapy • Ceftriaxone 500 mg IM as a single dose 8 • Side Effects: diarrehea, weakness, dizziness, heart palpitations, pale skin, headache, confusion, jaundice, chills, fever, back pain, and abdominal pain. Tell the doctor if you have any side effect that bothers you or that does not go away. Call your doctor for medical advice about side effects. Education Education • • • • • • The importance of using condom in order to avoid sexually transmitted infection. To be faithful to only one partner. Abstain from sex till the infection is fully treated. Early identification of complications that is associated with this infection. Importance of screening for other STI’s (Owusu et al, 2013). Always go for HIV counselling and testing whenever she has a new partner. Non-medical treatment. • • • • • • • Do not engage in unprotected sexual activity till both the patient and the partner is fully treated (O’Connor et al, 2014). Keep the perineal region clean by washing with unscented soap and water. Always put-on dry underpants. Inform the doctor whenever you have abdominal pain, fever and per vaginal discharge. Avoid pants that are tight in the crotch and thighs. Changes pads frequently. Reducing risk sexual behaviour (O’Connor et al, 2014)NUR 514 STU SOAP note for Endometriosis Women Health. Follow up: The patient will be followed up in the GYN clinic weekly till the infection is fully treated. During the follow up the following will be enquired:

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The resolution of symptoms Any complication that has risen Compliance to medication to both the patient and the partner. Referrals: None. Signature (with appropriate credentials): ______Estefania Batallas _______________ 9 Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________ DEA#: 101010101 STU Clinic LIC# 10000000 Tel: (000) 555-1234 FAX: (000) 555-12222 Patient Name: (Initials)_______K.J_______________________ Age __28_______ Date: ___3/24/2021__________ RX ___Ceftriaxone 500 mg /125 ml, IM X 1 dose. SIG: 1 vial Dispense: ____ Refill: _____N/A____________ No Substitution Signature: Estefania Batallas_________________________________________________ References CDC. A guide to taking a sexual history. Atlanta, GA: US Department of Health and Human Services, CDC. Available at http://www.cdc.gov/std/treatment/SexualHistory.pdf. O’Connor EA, Lin JS, Burda BU, et al. USPSTF: behavioral sexual risk-reduction counseling in primary care to prevent sexually transmitted infections. Ann Intern Med 2014;161:87483 Owusu-Edusei K Jr, Gift TL, Chesson HW, et al. Investigating the potential public health benefit of jail-based screening and treatment programs for chlamydia. Am J Epidemioly 2013;177:463–73. 10 Papp JR, Schachter J, Gaydos C, et al. Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae—2014. MMWR Recomm Rep 2014;63(No. RR-02). Symonds, E. M., Symonds, I. M., & Arulkumaran, S. (Eds.). (2013). Essential Obstetrics and Gynaecology E-Book. Elsevier Health Sciences NUR 514 STU SOAP note for Endometriosis Women Health