Nursing

Write Comprehensive Well-Woman Exam that addresses the following:

Age, race and ethnicity, and partner status of the patient
Current health status, including chief concern or complaint of the patient
Contraception method (if any)
Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)
Review of systems
Physical exam
Labs, tests, and other diagnostics
Differential diagnoses
Management plan, including diagnosis, treatment, patient education, and follow-up care
Provide evidence-based guidelines to support treatment plan. Note: Use your Learning Resources and evidence from scholarly sources from your personal search to support your treatment plan of care.
Reflection

Reflect on some additional factors for your patient:

What are the implications if your patient was pregnant or just delivered?
What are implications if you have observed or know of some domestic violence? Would this change your plan of care? If so, how?

PLEASE USE SOAP TEMPLATE

ANSWER

Focused SOAP Note Template

Patient Information:

AA, 33 years, Female, Asian.

S.

CC (chief complaint): AA, a 33-year-old female reports to the office for a follow-up after abnormal Pap smear and scheduled colposcopy. The patient claims that she is still experiencing intermittent abnormal uterine bleeding and pelvic pain.

HPI: AA defines the pain as a bilateral sharp sensation in the pelvic region that does not radiate. The symptoms begun a month ago and reports that the pain worsens after having sex.

Location: Pelvic

Onset: One month ago

Character: Bilateral sharp sensation in the pelvic region.

Associated signs and symptoms: Pain during intercourse

Timing: Unknown

Exacerbating/relieving factors: Treats the pain with OTC Ibuprofen 400mg

Severity: 7/10 pain scale at its worst but remains a 3/10 at all times

Current Medications: No current medications

Allergies: No allergies

PMHx: Unknown past medical history

Soc & Substance Hx: No social and substance history.

Fam Hx: No family history

Surgical Hx: No Prior surgical procedures.

Mental Hx: No mental history

Violence Hx: No violence history

Reproductive Hx: Regular periods but occasional spotting since the onset of her pelvic pain.

ROS:

GENERAL: AA complains of pelvic pain and uterine bleeding.

HEENT:

Head: Denies any headache

Eyes: No visual loss, eye pain, or double vision.

Ears, Nose, Throat: No ear pain, hearing impairment, nose bleeds, nasal obstruction, or tinnitus

SKIN: No itching, bruising, skin rashes, lacerations or open wounds.

CARDIOVASCULAR: No chest pains.

RESPIRATORY: Denies SOB or cough

GASTROINTESTINAL: Denies abdominal pains, vomiting or nausea

GENITOURINARY: Uterine bleeding and pelvic pain.

NEUROLOGICAL: No headache, numbness, paralysis, ataxia, syncope or dizziness.

MUSCULOSKELETAL: No muscle pains

HEMATOLOGIC: Denies bruising, bleeding or anemia.

LYMPHATICS: Denies enlarged nodes or history of splenectomy

PSYCHIATRIC: No anxiety or depression

ENDOCRINOLOGIC: No polydipsia or and no sweating or cold.

ALLERGIES: Denies asthma, rhinitis or hives.

O.

Physical exam: The initial examination of a patient with pelvic pain and uterine bleeding entails characterization of symptoms, review of systems, personal history, medical history and family history. Simple primary care tests were done to acquire relevant information regarding the patient condition. The diagnostic tests included MRI, urinalysis, CT scan, X-ray and blood test. Urinalysis was used to detect the disorders in the reproductive system. CT scan and X-ray were done to not pelvic prolapse and pelvic organ atrophy. The blood tests and MRI were done to examine some conditions linked to pelvic pain and urinary bleeding.

Diagnostic results: The diagnostic tests included X-ray, urinalysis, blood tests, CT scan and MRI which were used to develop differential diagnoses (Kruszka and Kruszka, 2010). Figuring out the causes of pelvic pain and uterine bleeding involves the process of elimination since there are different disorders that lead to pelvic pain and uterine bleeding.

A.

Differential Diagnoses

Pelvic Inflammatory Disease- This is an infection that occurs in the female reproductive system due to sexually transmitted bacteria such as gonorrhea and chlamydia that spreads from the vagina to the fallopian tubes, uterus and ovaries (Brunham, Gottlieb and Paavonen, 2015). PID has signs and symptoms similar to the patient complains such as serve pain on the pelvic area and abnormal uterine bleeding that occurs after intercourse and during the menstrual cycle.

Endometriosis- Endometriosis is an unusual growth of endometrial cells outside the uterus. This is a painful disorder that occurs in tissues inside the uterus and mostly involves fallopian tubes, ovaries and tissue lining of the pelvis. The painful disorder causes pain during menstrual periods and pain during or after sex. Individuals with endometriosis experience excessive bleeding during menstruation.

Raptured Ovarian Cyst- Raptured ovarian cyst is a rapture that can result to internal bleeding and severe pain. This cause a sudden and sharp pain on the pelvic area. One might feel pain during or after sex. The pain that occurs from an ovarian cyst is likely to occur at the midpoint of the menstrual cycle.

Uterine Prolapse- Uterine prolapse occurs when the uterus has descended into or towards the vagina. The pelvic ligaments and floor muscles become weak and are unable to support the uterus (Seitz and Goldberg, 2017). This causes pain in the lower abdomen and pelvis area and a feeling of heaviness or pressure on the pelvis. Uterine prolapse also causes abnormal bleeding and increased vaginal discharge.

During the treatment plan and diagnosis, the patient factors, physical examination and socioeconomic factors were used to examine the patient’s conditions. The analysis of the patient condition focused on family, personal, social and medical history to determine health condition. The treatment plan is customized to the condition and diagnosis of the patient. Subject to the cause the physician will commend a several medications to manage the situation.  Hormone treatment, over the counter treatment, pain relievers, antibiotics and antidepressants will be used to relieve the pelvic pain. For instance, a combination of antibiotics will be prescribed for the treatment of pelvic inflammatory disease. The patient education will focus on reducing the symptoms and boosting the quality of life. This will pinpoint the specific causes and treatment that will reduce the pelvic pain. After treatment a 30-day follow up visits will be scheduled to ensure that the treatment is working.

I agree with the preceptor’s treatment of the patient since PID is treated with a combination of antibiotics that provide empiric and a wide spectrum of pathogens. Prompt treatment with medicine can help prevent the infection that leads to pelvic inflammatory disease. I learnt that the treatment plan and diagnosis should focus on the medical, personal and family history of the patient. However, on the treatment plan I would also focus on long term treatment options to prevent the infection. Additionally, health promotion and disease prevention should focus on different patient factors such as family, cultural background, personal history, and socio-economic factors. These factors play an essential role in determining some of the reasons linked to the patient’s condition.

If the patient experiences pelvic pain and uterine bleeding after pregnancy, the most effective treatment approach would be occupational and physical therapy. These would play an essential role in restoring the normal joints and muscle movements of the pelvis. Exercises would also be suitable for strengthening the pelvic floor. The treatment plan would take a different approach in case the patient claims to be a victim of domestic violence. For instance, lifestyle changes such as regular exercise and nutritional therapy would enhance the treatment plan.

References

Brunham, R. C., Gottlieb, S. L., & Paavonen, J. (2015). Pelvic inflammatory disease. New England Journal of Medicine, 372(21), 2039-2048.

Hamid, R., & Losco, G. (2014). Pelvic organ prolapse-associated cystitis. Current bladder dysfunction reports, 9(3), 175-180.

Kruszka, P., & Kruszka, S. J. (2010). Evaluation of acute pelvic pain in women. American family physician, 82(2), 141-147.

Seitz, M., & Goldberg, R. P. (2017). Uterine Prolapse. In Textbook of Female Urology and Urogynecology-Two-Volume Set (pp. 1004-1015). CRC Press.