NURS 6551: Primary Care of Women – Sample SOAP Note

NURS 6551: Primary Care of Women – Sample SOAP Note

NURS 6551: Primary Care of Women – Sample SOAP Note

SOAP Note Week 3

Date: xxxx

Name: TS          Age: 33          Gender: Female          Race: Caucasian

SUBJECTIVE NURS 6551 Practicum Focused SOAP Note and Time Log

Chief Complaint: TS came to the clinic with complains of unusual bleeding and discharge, difficulty urinating, pain around vaginal area, pain during intercourse and abnormal pap results.

HPI: The patient presented with painful urination, vaginal discharge and coitus pain. She also noted an increase in vaginal bleeding, Pap tests taken have been abnormal and pelvic area has also been experiencing pain. This has been going on for two weeks, for which she has been using OTC Ibuprofen.

PMH:

Allergies: None

Current Medication: Ibuprofen 600mg BD.

Immunization: Up to date

Previous Routine Tests: A normal pap smear 6 months ago

Past Illnesses: Recurrent UTI.

Hospitalizations: None.

Pregnancy History: G0 P0 A0

Family History: Mother has Type 2 Diabetes, Father has Hypertension, No siblings;  She lives with husband who has Arthritis.

Social History: She is an occasional smoker and is a social drinker. She denies use of illicit drugs. She tries to stay active by doing Zumba dance during free times. She works as a Lyricist for a music company. NURS 6551 Practicum Focused SOAP Note and Time Log

ROS:

Constitutional: The patient appears unwell and is worried that the symptoms are gradually increasing and it has even started to affect his day to day life because of the pain. She denies incidences of fever, diarrhea, nausea and weight gain or loss.

HEENT: No headache, head bruises or rashes. Hearing capability seems normal. Uses reading glasses.

Cardiovascular: Normal heart rate and denies any murmurs, gallops and clicks.

Respiratory: The chest rises and falls rhythmically with the patient not complaining of wheezing, and coughing.

Gastrointestinal: Denies diarrhea, abnormal bowel movements and pain in the abdomen.

Genitourinary: Complains of pain while urinating, painful coitus, pain in the pelvic area, vaginal discharge and abnormal bleeding. Patient denies hematuria, urgency and frequency in urination.

Musculoskeletal: The patient denies any pain in the muscles, back pain or pain in the joints.

Neurologic: The patient has no deformities with the balance and is sensitive to the stimuli. NURS 6551 Practicum Focused SOAP Note and Time Log

Psychiatric: Denies insomnia, nightmares, suicidal thoughts and abnormal headache.

OBJECTIVE:

Constitutional: T 97.5F, BP 114/71, HR 77, RR 23, Ht 4” 5’, Wt 146lbs

General: The patient is well groomed and responds questions. She looks distressed.

Head: No deformities or poor hair growth observed.

Eyes: Sclera white, normal light sensitivity and no abnormal discharge, no redness

Ears: Bilaterally intact, TM intact, no discharge

Nose: Pink and Moist mucosa, no sneezing or excessive discharge or congestion, no polyps

Throat: No Inflammation, swelling or dislocation.

Mouth: Oral mucosa is pink and moist

Cardiovascular: RRR, no murmurs, clicks or gallops. S1 and S2 present, capillary refill <3 seconds.

Respiratory: Chest clear, no wheezing or rales

Gastrointestinal: No diarrhea or constipation; generalized tenderness; bowel sounds present in all 4 quadrants.

Genitourinary: Painful urination, painful coitus, pain in the pelvic area, vaginal discharge and abnormal bleeding, no hematuria, urgency and frequency in urination.

Musculoskeletal: Normal gait, no muscular tenderness or swelling NURS 6551 Practicum Focused SOAP Note and Time Log

Neurologic: The patient has normal gait, responds effectively to all temperature extremes.

Psychiatric: No insomnia, nightmares, suicidal thoughts.

Labs: Pap smear, endometrial biopsy, Curettage and dilation, transvaginal ultrasound and Computed tomography.

ASSESSMENT

Diagnosis:  Endometrial cancer

Endometrial cancer: This refers to a type of cancer that majorly affects the uterine lining makes the cells to grow abnormally to the point where they can affect other body parts (Shafer & Van Le, 2013). During early onset of the condition, there will be excessive vaginal bleeding that does not have a relationship with menstrual periods. The other symptoms include painful sex, pain while urinating, vaginal discharge and painful pelvic area (Kulkarni & Harshavardhan, 2017). The Pap smear showed abnormal results of glandular cells that are abnormal. All the other tests were positive for endometrial cancer.

Endometrial Hyperplasia: Common presentation is abnormal uterine bleeding. In premenopausal women, the symptoms include irregular heavy menstruation or amenorrhea in some cases. Endometrial biopsy differentiates endometrial hyperplasia from cancer. However there in 42.6% cases of endometrial cancer, the initial diagnosis was hyperlasia with atapia (Endometrial Cancer, 2018). NURS 6551 Practicum Focused SOAP Note and Time Log

Endometriosis: Symptoms include pain, dyspareunia and painful defecation. It is common in young premenopausal women. Physical examination reveals tenderness and nodularity. Pelvic ultrasound can be done to confirm endometrioma (Endometrial Cancer, 2018).

PLAN:

The ideal treatment for this cancer is through surgery where the tumor will be removed (Shafer & Van Le, 2013). Additionally, some of the healthy tissues that surround the tumor will be removed since they could be containing some cancer cells. Simple Hysterectomy will be ideal for the patient due to the extent of the spread of the cells (Eifel, 2015).  In this case, the cervix and uterus will be removed since the cancer cells have not spread so much to the other parts of the reproductive system.

The patient will have to keep visiting the health facility after the procedure for routine maintenance and test to ascertain that the tumor does not regenerate. NURS 6551 Practicum Focused SOAP Note and Time Log

Reflection notes:

In this case, the diagnosis itself is a big shock to the patient. Also, the pain suffered by TS is limiting her from his daily activities. Ignoring these could attribute to mood disorders or depression. She should be introduced to support groups with people going through the same diagnosis. This will also help her overcome the mental and physical pain caused by the disease. NURS 6551 Practicum Focused SOAP Note and Time Log

ADDITIONAL INSTRUCTIONS FOR THE CLASS

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Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

• Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

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Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

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I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

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For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score. NURS 6551: Primary Care of Women – Sample SOAP Note

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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