Nursing

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What would you do differently in a similar patient evaluation?

ANSWER

Episodic/Focused SOAP Note Template

Patient Information:

AAP, 49 Year Old, Female

S.

CC (chief complaint): APP visits the clinic complaining of abnormal bleed and pelvic pressure.

HPI: AAP a 49 year old, female has a past medical history of anemia, Grave, hypertension, osteopenia and obesity.

Location: Pelvic

Onset: 16 days

Character: Abnormal bleeding

Associated signs and symptoms: Pelvic pain

Timing: unknown

Exacerbating/relieving factors: Not stated

Severity: 7/10 pain scale

Current Medications: Aspirin, metoprolol and progestin mini pills. She takes metoprolol to lower blood pressure and the risk of heart attacks and strokes. She takes aspirin to lower the risk of blood flow problems and heart attack.

Allergies: She is allergic to PCN. Penicillin allergy is an abnormal reaction to the antibiotic drug penicillin by the immune system. Therefore, APP should prevent all drugs that are in the immediate family of penicillin.

PMHx: Anemia, Grave disease, obesity, osteopenia and hypertension. She has a surgical history of tubal ligation.

Soc & Substance Hx: APP works full time as a pharmacy assistant. She lives an inactive lifestyle with insignificant exercise 1-2 times on weekly basis. She puts on her seatbelts in the car and negates texting while driving. Her father passed but her mother is alive. She does not use illegal substances or cigarettes but states that she takes 1-2 glasses of wine weekly.

Fam Hx: Father died out of heart attack at 47. Mum is still alive at 85 but has a history of obesity and hypertension.

Surgical Hx: Tubal ligation surgery

Mental Hx: No significant diagnosis and treatment of mental health.

Violence Hx: No significant violence history

Reproductive Hx: The onset of menses began at the age of 14. She experiences heavy bleeding and irregular menses since the age of 48. She also has some pelvic pain, cramping and pressure with menses. She has used progestin mini pills a birth control contraceptive.

ROS:

GENERAL: APP complains of abnormal bleeding and pelvic pain.

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 palpitations, chest pains or chest discomfort.

RESPIRATORY: Denies SOB, shortness of breath, cough, and no sputum,

GASTROINTESTINAL: Denies abdominal pains, nausea, diarrhea or vomiting.

GENITOURINARY: Abnormal bleeding and pelvic pain.

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

MUSCULOSKELETAL: No muscle pains

HEMATOLOGIC: Dnies bruising, bleeding or anemia.

LYMPHATICS: No enlarged nodes. No history of splenectomy

PSYCHIATRIC: No depression or anxiety.

ENDOCRINOLOGIC: No polydipsia or and no sweating or cold.

ALLERGIES: Denies asthma, rhinitis or hives.

O.

Physical exam: The physical examination of the patient involved beginning of the symptoms, characterization of symptoms, medical history, personal history and family history. The examination also included diagnostic tests and vital signs. The diagnostic tests included urinalysis, MRI, CT scan, X-Ray and blood test. The diagnostic tests significantly revealed abnormal growths and infection.

Diagnostic results:

The MRI, CT scan, blood test and X-ray confirmed that the patient had pelvic inflammatory disease.

A.

Differential Diagnoses

Pelvic inflammatory Disease – This is an infection on the female reproductive organs that occurs due to sexually transmitted bacteria. The signs and symptoms include pain in the pelvic area ranging from mild to severe, heavy and abnormal discharge, abnormal uterine bleeding between menstrual cycles as well as during and after intercourse (Curry, Williams and Penny, 2019). Pelvic inflammatory disease is the primary diagnosis since the patient presents the stated symptoms and is common among women due to the infection caused by a bacteria.

Ruptured Ovarian Cyst- This disease causes sudden pain the pelvic area. Some ruptured ovarian cysts lead to a lot of bleeding. It’s also associated with nausea and vomiting, increased pain while sitting, fever, feeling faint and weakness (Lim, Woods and Lamaro, 2021).

Appendicitis- This is the inflammation of the appendix that projects from the colon to the lower right side of the abdomen. It causes pains in the lower right abdomen but in most people the pain starts around the navel (Ferris et al., 2017). Appendicitis is associated with cramps and pain on the left and right of the lower abdominal region. It occurs along with vaginal bleeding and loss of tissues or fluid from the vagina.

Health promotion and disease prevention focus on ensuring that people are healthy. During the diagnosis and treatment there is need to focus on changes that will reduce the risk of developing the pelvic inflammatory disease and other morbidities. Additionally, paying attention to the patient factors, past medical history and socioeconomic factors is essential in building a patient professional relationship as well as understanding the human factors affecting the patient. The socioeconomic and family status are essential in uncovering various conditions that are linked to the patient’s disease.

Diagnosis and treatment includes analysis of the patient condition through a focus on the personal history, social, family, and medical history. Considerably, these assessments offers a clue of the underlying diagnosis and provide key evidence from the cause lists which can help in accurate diagnosis. The diagnostic tests and results help in locating specific health or disease condition. Pelvic inflammatory disease can be treated effectively with antibiotics. After starting the treatment, the patient needs to complete the prescribed medication since the infection can spread to other body parts. The male partners should also be involved in the prevention and management plans. Educating the patient on how to adopt healthy behaviors can facilitate effective treatment. As a healthcare providers, I would focus more on physical assessment to obtain more objective and subjective data thus scrutinizing more signs and symptoms that are currently occurring. This would assist in accurate diagnosis of the patient condition.

References

Curry, A., Williams, T., & Penny, M. L. (2019). Pelvic inflammatory disease: diagnosis, management, and prevention. American family physician, 100(6), 357-364.

Ferris, M., Quan, S., Kaplan, B. S., Molodecky, N., Ball, C. G., Chernoff, G. W., … & Kaplan, G. G. (2017). The global incidence of appendicitis: a systematic review of population-based studies. Annals of surgery, 266(2), 237-241.

Lim, W. H., Woods, N., & Lamaro, V. P. (2021). Trends and outcomes of ruptured ovarian cysts. Postgraduate medical journal.