| SOAP Note | Rationale |
| Demographic Info:
Name: PRT Age: 45-years-old Sex: Female Race: Hispanic
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Assessments of the patient’s biodata ensures that the important information about the patient is denoted for the major reasons for data recording. However, like the case of uterine fibroids, the disease is much prevalent among older women and thus denoting the age of the patient and sex helps in assessing the risk factors of the patient. |
| SUBJECTIVE: | |
| CC: ‘pain on my pelvic region and an increasingly growing mass on my abdomen’’ | Chief complaint is the primary reason the patient is seeking medical services. Thus, it initiates the subjective assessment of the patient which later on gives the progress of the objective and further care plan of the patient. Additionally, it denotes the patient’s problem and the differential diagnosis of the patient. In this case, the patient may be suffering from uterine fibroids, endometriosis, pelvic inflammatory disease or even dysmenorrhea. Thus, further patient health assessment will focus on this differential diagnosis. |
| HPI: The patient is a 45-year-old Hispanic woman who presented to the medical facility with initial complaints of pelvic pain and an increasingly growing mass in her abdomen. She states that the pelvic pain is worse during her menses but she has not perceived her menses for two months now. Additionally, the pain has been there for about two years now. The pain radiates to the back and is associated with abdominal fullness, tiredness and increased by physical activities and relived by rest. Additionally, she rates her pain as 5 on a scale of one to ten. She however started feeling the mass about two months ago, it all started as a small growing mass that has been increasing in size. She is worried because the mass is increasing in size and it not being controlled by anything or even medications. | The patient’s HPI is strategically recorded in a format that expounds ns more on the presenting chief complaints of the patient. In this case, the HPI has denoted the pertinent positives to uterine fibroids like an increasingly growing abdominal mass, pelvic pain and an increased age. However, the other factors must also be considered before making the final diagnosis. |
| PMHx: No past medical illnesses | Assessing the patient’s underlying illnesses helps in denoting any additional risk factors that may be associated with his current illness. However, in this case there are no positive findings of any additional predisposing illnesses that can cause or aggravate her illness. |
| Surgeries: Appendicectomy at 16 years | There are past surgeries that can cause the patient’s current illness. Assessing past surgeries helps in demoting any risk factors to the current patient’s illness. In this case, the patient’s past surgeries have no implications to her current illness. |
| OB/GYN: She is a para 2+0. Menarche was at 15 years, with a regular cycle of 28 days. Her flows last for 5 days with using two moderately socked sterile sanitary pads. She has no history of dysmenorrhea but she started feeling pain during her menses about two years ago and has not been reducing. She has been on long-term IUCD. | Her current presenting symptoms calls for a comprehensive OB/GYN assessments. This is because, individuals with few children have a high risk of uterine fibroids. Additionally, from her assessment, it seems that she is at major risk of developing uterine fibroids. |
| Fam Hx: Her mother succumbed to Hypertension but had uterine fibroids. Her father has T1DM. Her brother and sister are alive and well. | Familial history is essential because there are some diseases that are related to genetics. In this case, her familial predisposing of uterine fibroids places her at higher risk of developing uterine fibroids as well. |
| Soc Hx: She reports smoking about two sticks of cigarette per day. She has been smoking for three years now. She however denies using any alcohol nor use of any illicit substances. | From review of her social history, her history of using cigarette predisposes her to developing uterine fibroids. Additionally, social history of the patient determines their health lifestyles and thus must be fully assessed and reviewed when developing the care plan of the patient. |
| Allergies: She is allergic to penicillin with rash that begins from the face to the trunk. | Assessing allergies is essential so that it can be fully prevented from recurring. In this case, the patient is allergic to penicillin and thus her medications will be lacking penicillin. |
| Current Meds: Tylenol PO 1 gram | There are some medications that have detrimental side effects that are associated with illnesses. In this case, she only uses Tylenol for her pain and thus, there are no implications or associations between her current illness and her medications. |
| Immunizations: Her immunizations are up to date. She received her flu shot on September 2021. | Some immunizations are used to prevent diseases. From her immunization review and her current illness, there are no associations to her current presenting illness. |
| ROS: | |
| General/Constitutional: Reports pelvic pain and an increasing growing abdominal mass. She reports increased tiredness when experiencing the pelvic pain. She denies fever, any breast symptoms, weight loss, or any other additional symptoms. | Gives insight to the patient’s illness and state of health. |
| HEENT: Denies headache, ear discharges, ear pain, eye pain, nor any visual problems. Denies throat pain, difficulty or problems swallowing, neck pain nor any oral problems. | Assesses any HEENT associated symptoms to see if the disease has affected the system. |
| Breast: Denies breast pain, breast lumps, skin color changes, wrinkling nor nipple discharges. | Assessing the breast for any symptoms is very critical. In this case, all her symptoms are negative and thus the breast is not affected in any way. |
| Cardiovascular: Denies palpitations, orthopnea, left sided chest pains, cough nor problems breathing. | Assesses if the CVS has been involved. |
| GI: Reports abdominal fullness and increasingly growing mass. Reports bloating intermittently. Denies changes in appetite, nausea, vomiting, diarrhea, chest pain, heartburn, Malena or any passing dark stool or blood in stool. | Helps in assessing if the GI has been affected. With her current presenting symptoms, the GI has been affected with pertinent positives of abdominal fullness, intermittent bloating and an increasingly growing abdominal mass. |
| GU: Reports only pelvic pain but denies vaginal discharges, dyspareunia, hematuria, dysuria, changes in urine color, nor hematuria. She reports that her mammogram and pap smear were dan on August 2020 with negative results. | Pertinent positives include pelvic pain. This assessment is essential with her current presenting illness. |
| Psych: Denies stress, depression, nor any suicidal ideations but is reportedly anxious about her current condition. | Her current illness has resulted to her experiencing anxiety. Thus, patient reassurance will help in reducing her anxiety. |
| Neuro: Denies dizziness, confusion, light-headedness nor headaches. | Assesses if her Neuro has been affected and all symptoms are negative. |
| OBJECTIVE: | |
| VS: BP 128/90 mmHg, Temp 98F, PR 80, Wt 160lbs, Ht 66, BMI 24.6. | Her vital sign assessment denotes no abnormality recurring urgent care. |
| General Appearance: The patient appears oriented of time, place and person. She appears well nourished, well dressed, she is very cooperative with the examination, answers questions as required and has good eye contact. | This offers ideations to the patient’s eligibility to continue with the assessment. In this case, the patient is well progressive with the assessment. |
| Breast: No tenderness, no wrinkling, no nipple discharges nor any denoted lumps or masses. | The breast is not affected. |
| Heart: Normal S1S2 with no denoted S3S4. Normal cap refill with no deviated apex beat. | Helps in ruling out any differential that kay affected the CVS. |
| Abdomen: Slightly distended abdomen, no scars or lesions, moves with respiration. There is small mass on the lower abdomen on the lumbar region on palpation with mild tenderness. | Denotes pertinent positives of abdominal mass and tenderness. |
| GUT: Normal external genitalia, pink, no masses nor lesions nor any denotable trauma. Even hair distribution. No abnormalities detected. Palpable uterus with a moderately swollen mass that is slightly tender. | Denotes the pertinent positives of slightly tender uterine mass. This denotes the diagnosis of uterine fibroid and rules out dysmenorrhea, PID or endometriosis. |
| Laboratory & Diagnostic Testing: | This will help in expounding on the findings of subjective and objective assessments. It will thus give a clear cause of the patient’s problem and will rule out the other differential diagnoses. |
| Transvaginal ultrasound (Stewart, Cookson, Gandolfo & Schulze‐Rath, 2017). | Denotes the diagnosis of uterine fibroids |
| Hysteroscopy | Denotes any benign growths in the uterus like fibroids |
| Laparoscopy (Stewart, Cookson, Gandolfo & Schulze‐Rath, 2017). | To rule out endometriosis and dysmenorrhea. |
| Complete blood count (Stewart, Cookson, Gandolfo & Schulze‐Rath, 2017). | To rule out pelvic inflammatory disease. |
| ASSESSMENT: | |
| Differential diagnosis
· Pelvic Inflammatory Diseases: This is the most likely differential diagnosis. Pertinent positives include current complaints of long-term pelvic pain that is on a scale of 5 and not relieved by any medications (Stewart et al., 2016). Also, fatigue and pain during menstruation denotes PID as the differential diagnosis. In addition to the uterus, fallopian tubes, and the ovaries, the bladder is also affected. An inflammation of the ovaries, oviducts, and surrounding tissues, known as Pelvic Inflammatory disease (PID), is a medical term for this ailment. Aside from bacterial infections such as N. gonorrhoeae and C. trachomatis, PID disorders can also be caused by viruses or parasites (Stewart et al., 2016). The chance of PID exists, but it’s extremely unlikely when you consider all of the conflicting evidence. PID, STIs, or changes in vaginal discharge have never been a problem for these people (Stewart et al., 2016). You should look into PID if you’re experiencing lower abdomen and pelvic pain that is on both sides. |
In this case, PID is the most likely differential diagnosis due to the patient’s current presenting illness. However, assessing this differential is a key factor in developing the final diagnosis of the patient. Thus, through a complete blood count, it will be ruled out so that the final diagnosis can be made and the care plan of the patient can be developed strategically addressing the patient’s actual problem. |
| · Endometriosis: This is another likely differential in this patient’s case. The pertinent positives include increasing pelvic pains with increasing pain during menstruation, with the pertinent negatives being dyspareunia, infertility and dysuria (Stewart, Cookson, Gandolfo & Schulze‐Rath, 2017). To put it simply, endometriosis is an abnormal proliferation of cells that are identical to those found in the uterus (endometrial cells), but occur outside of it. Every month, a similar number of endometrial cells are shed during the feminine cycle. Among women of reproductive age, endometriosis is common, but its clinical findings can vary greatly depending on the implant size, number, and degree of treatment. Endometriosis is estimated to affect more than 1 million women in the United States (gauges range from 3% to 18% of women) (Stewart, Cookson, Gandolfo & Schulze‐Rath, 2017). The most common symptoms of endometriosis are infertility, dysmenorrhea, and dyspareunia. Dysmenorrhea is a recurring issue for this patient. There is a possibility that endometriosis may be present, but a formal diagnosis cannot be made without further testing. | This is another likely differential diagnosis due to the current presenting symptoms of the patient. This denotes the need for laboratory assessment to rule out the differential and assist in making the final diagnosis so that the care plan can be patient-need centered. |
| · Dysmenorrhea: This differential is least likely. However, it is considered due to the pertinent positives of pelvic pain and increasing menstrual pains. However, the pertinent negatives include nausea, vomiting and lower abdominal pains (De La Cruz & Buchanan, 2017). Dysmenorrhea is a term used to describe symptoms that interfere with a woman’s daily life, such as menstrual cramps. Other common side effects, including as headache and diarrhea, are common. Most cases of dysmenorrhea that occur after the age of 30 are the result of an underlying medical condition (De La Cruz & Buchanan, 2017). Tolerable periods of discomfort can range from one to five days depending on the cycle, and the pain might worsen with age. Dysmenorrhea should be evaluated as a possible diagnosis given the patient’s age and recent history of painful periods. | Dysmenorrhea is a least likely differential in this case due to most of its symptoms being negative. However, it must be ruled out before making the final diagnosis and developing care pan of the patient that fully addresses her diagnosis (De La Cruz & Buchanan, 2017). |
| Final diagnosis: Uterine Fibroids: This is the patient’s final diagnosis. It is supported by the pertinent positives of pelvic pain and menstrual pain, increasingly growing abdominal mass and uterine mass on palpation with slight tenderness (De La Cruz & Buchanan, 2017). Additionally, the familial history of fibroid where her mother presented with positive findings places her at high risk of developing the condition. These features denote the diagnosis of uterine fibroids. The pertinent negatives of this diagnosis include constipation, intermenstrual bleeding and dyspareunia. A uterine fibroid is an unfavorable tumor of the uterus’s smooth muscle that may be benign (De La Cruz & Buchanan, 2017). It’s common for fibroids to create symptoms such as irregular uterine bleeding, pelvic pain and pressure, as well as symptoms of urinary and intestine origin, throughout pregnancy. A pelvic exam, ultrasound, or other imaging method is used to do this procedure. 70 percent of women over 45 are diagnosed with uterine fibroids, the most common pelvic tumor (De La Cruz & Buchanan, 2017). As a result, the majority of fibroids are tiny and asymptomatic. More than half of all women in the United States are affected by uterine fibroids at some point. | Uterine fibroids are the final patient’s diagnosis. This is due to the supportive evident presented by the patient. Additionally, the laboratory and radiological findings denotes this uterine diagnosis (De La Cruz & Buchanan, 2017). The care plan will thus be specified to addressing treatment to uterine fibroids and will also address the risk factors that are presented with the patient.
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| PLAN: | |
| Medications: 1 gram TDS Acetaminophen PO to continue. Tranexamic acid PO 500mg BD for five days. Tylenol 1 gram TDS for five days (Giuliani, As‐Sanie & Marsh, 2020). | These medications will help in shrinking the uterine fibroids and relive the pain. |
| Education: Educate the patient to reduce intake of glucose, table sugar, dextrose, high fructose corn syrup, maltose, and foods that have a lot of sugar intake (Giuliani, As‐Sanie & Marsh, 2020). She must also stop smoking cigarette. | These measures will help in reducing the uterine growth. Additionally, these health promotion measures must be reduced and must be followed for improved patient outcomes. |
| Non-medications: If the size of the fibroids is large, then myomectomy must be done to remove them (Giuliani, As‐Sanie & Marsh, 2020). However, uterine artery embolization can be used to shrink the fibroids. | This will offer definitive cure against the fibroids. |
| Follow-up: Twice weekly follow-ups through a gynecologist (Giuliani, As‐Sanie & Marsh, 2020). | These follow-ups will aid in evaluating the patient’s treatment results and in identifying any symptoms that may arise (Giuliani, As‐Sanie & Marsh, 2020). The patient will also be evaluated on her living habits throughout these evaluations to ensure that she is on a healthy path (Giuliani, As‐Sanie & Marsh, 2020). Additionally, the patient will have a thorough health check, including a mammogram and cervical cancer screening. |
| COMMENTS: | |
| At the beginning of the assessment, the patient was very anxious but after the assessment, she was reassured and regained her confidence. Health education was given very well and will be followed to the latter to improve her health outcomes. | Patients are typically concerned about their health when they go to the doctor’s office. They need us to calm them down and provide health advice (Giuliani, As‐Sanie & Marsh, 2020). Health evaluations and patient encounters can be improved by creating a welcoming setting. |
References
De La Cruz, M. S. D., & Buchanan, E. M. (2017). Uterine fibroids: diagnosis and treatment. American family physician, 95(2), 100-107. https://www.aafp.org/afp/2017/0115/p100.html
Giuliani, E., As‐Sanie, S., & Marsh, E. E. (2020). Epidemiology and management of uterine fibroids. International Journal of Gynecology & Obstetrics, 149(1), 3-9. https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1002/ijgo.13102
Stewart, E. A., Cookson, C. L., Gandolfo, R. A., & Schulze‐Rath, R. (2017). Epidemiology of uterine fibroids: a systematic review. BJOG: An International Journal of Obstetrics & Gynaecology, 124(10), 1501-1512. https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/1471-0528.14640
Stewart, E. A., Laughlin-Tommaso, S. K., Catherino, W. H., Lalitkumar, S., Gupta, D., & Vollenhoven, B. (2016). Uterine fibroids. Nature reviews Disease primers, 2(1), 1-18. https://www.nature.com/articles/nrdp201643
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