OB/GYN SOAP Note

Gynecologic Health

Select a patient that you examined as a nurse practitioner student during the last three weeks of clinical on OB/GYN Issue. With this patient in mind, address the following in a SOAP Note 1 OR 2 PAGES :

Subjective: What details did the patient provide regarding her personal and medical history?

Objective: What observations did you make during the physical assessment?

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnosis. 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 for this patient , as well as a rationale for this treatment and management plan.

Very Important:  Reflection notes: What would you do differently in a similar patient evaluation?

Reference

Gagan, M. J. (2009). The SOAP format enhances communication. Kai Tiaki Nursing New Zealand, 15(5), 15.

Tharpe, N. L., Farley, C., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & Women’s health (4th ed.). Burlington, MA: Jones & Bartlett Publishers.

Chapter 6, “Care of the Well Woman Across the Life Span” ,“Care of the Woman Interested in Barrier Methods of Birth Control” (pp. 275–278)

Chapter 7, “Care of the Woman with Reproductive Health Problems”

“Care of the Woman with Dysmenorrhea” (pp. 366–368)

“Care of the Woman with Premenstrual Symptoms, Syndrome (PMS), or Dysphoric Disorder (PMDD)” (pp. 414–418)

SOAP Note

Subjective: The patient is a 32-year-old female who presented to the clinic with a chief complaint of severe pelvic pain and irregular menstrual cycles. She reported that the pain has been progressively worsening over the past six months, especially during menstruation. The patient has a history of heavy menstrual bleeding and significant discomfort during her periods. She denies any recent changes in sexual activity, contraceptive use, or recent pregnancies. She also mentioned experiencing mood swings and irritability during her menstrual periods.

Objective: During the physical assessment, the patient appeared in moderate discomfort. Vital signs were within normal limits. Abdominal examination revealed tenderness in the lower abdomen and a palpable mass on the right side of the pelvis. No abnormal vaginal discharge or odor was noted during speculum examination. Pelvic ultrasound was ordered and performed, revealing a 5 cm ovarian cyst on the right ovary.

Assessment: Differential Diagnoses:

1. Ovarian Cyst: The primary diagnosis is an ovarian cyst due to the patient’s history of severe pelvic pain and the presence of a palpable mass on ultrasound.
2. Endometriosis: Given the patient’s symptoms of dysmenorrhea and worsening pain during menstruation, endometriosis is a possible secondary diagnosis.
3. Premenstrual Dysphoric Disorder (PMDD): The patient reported mood swings and irritability during her menstrual cycles, which may suggest PMDD as a contributing factor.

Plan:

1. Diagnostics:
   • Further imaging: Order a pelvic MRI for a more detailed assessment of the ovarian cyst.
   • Hormonal panel: To rule out hormonal imbalances related to the menstrual irregularities.
   • Endometrial biopsy: If indicated based on ultrasound findings and hormonal profile.
2. Primary Diagnosis and Treatment:
   • Ovarian Cyst: If the ovarian cyst persists and is causing significant pain or complications, consider laparoscopic cystectomy or medical management with hormonal therapy.
   • Endometriosis: If confirmed, manage with hormonal therapy or surgical intervention.
   • PMDD: Recommend lifestyle modifications, stress management, and consider pharmacologic treatment if symptoms are severe.
3. Follow-up:
   • Schedule a follow-up appointment in two weeks to discuss diagnostic results and finalize the treatment plan.
   • Educate the patient about the importance of symptom monitoring and seeking immediate medical attention if she experiences worsening pain or any unusual symptoms.

Reflection Notes: In a similar patient evaluation, I would consider discussing contraceptive options and the potential benefits of hormonal contraceptives in managing symptoms related to endometriosis and PMDD. Additionally, I would emphasize the importance of maintaining open communication with the patient to address any concerns or questions she may have regarding her condition and treatment plan.