Case Study For Obstetrics Focused SOAP Note Assignment
Case Study For Obstetrics Focused SOAP Note Assignment
By Day 1 of this week, you will be assigned to a specific scenario for this Discussion. Please see the “Course Announcements†section of the classroom for your assignment from your Instructor.
Review the Learning Resources for this week as well as Weeks 5 and 6 and specifically review the clinical guideline resources specific to your assigned case study.
Use the Focused SOAP Note Template found in the Learning Resources to support Discussion. Based on the case study scenario provided, complete a SOAP note and critically analyze this and focus your attention on the diagnostic tests Case Study For Obstetrics Focused SOAP Note Assignment.
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Case Study 4
Case Study: Obstetrics
Scenario 1
Phillipa Hudson is a 29-year-old female presenting today at your clinic with a positive home pregnancy test. Her medical history is negative. Surgical history negative. Gyn history 1st menses age 12, with cycles coming every 28 days and lasting for 5 days. Her pap and std history are negative. She has been taking a woman’s gummy vitamin for the past year. Her OB history is as follows:
Date gestation outcome gender wt. anesthesia complications
1-2011 6 TAB None
4-2014 39 Low forceps delivery male 8’14†epidural Gestational diabetes
5-2016 8 weeks SAB
8-2016 35 weeks NSVD female 6’6†local None
7-2017 38 weeks SVD male 8’10†local Gestational diabetes
Phillipa relates her last period (LMP) was 04-04-2022. She reports breast tenderness, fatigue, and nausea (which is what made her suspect she was pregnant).
• Smoking/Alcohol/recreational drug use. Any potential chemical exposures at home or work. Social history such as relationship status, living situation, support system, job type, dietary restrictions.
Update: Height, weight, vital signs
Phillipa denies smoking, alcohol, and recreational drug use. She is a warehouse supervisor at Amazon and works 36 hrs. per week. She and her fiancé have been together for 5 years, and he works in an accounting office. They live in a 3-bedroom townhouse within easy walking distance to schools and stores. Her fiancé’s parents live in the same complex they do, and her parents and younger sister live about a mile away. Phillipa relates she is become a vegetarian since her last pregnancy.
Her vital signs at her first visit height 5’4†weight 176 lbs. and her BP is 112/68 Case Study For Obstetrics Focused SOAP Note Assignment
SUBJECTIVE DATA:
Chief Complaint (CC):
History of Present Illness (HPI): Phillipa Hudson is a 46-year-old African American female patient who presented earlier today with complaints of breast tenderness, fatigue, and nausea. She reported a positive home pregnancy. She also reported taking no medication for the symptoms.
Medications:
- Women’s gummy vitamin for the past year
Allergies: Drugs – None; food-none; environmental- none
Past Medical History (PMH): No past major illness
Past Surgical History (PSH): No history of surgery
Sexual/Reproductive History:
Heterosexual
Have one sexual partner
Do not use any protection
Not on any family planning method
Immunization History:
COVID-19 Vaccine #1 3/21/2021 #2 5/19/2021 Pfizer BioNTech – Comirnaty
Booster shot 6/16/2021 Pfizer BioNTech – Comirnaty
Up-to-date with childhood vaccines
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Social History:
Never smoked
Denied ETOH or illicit drug use.
No potential chemical exposures at home or work
Lifestyle:
Phillipa Hudson is the firstborn in a family of two, born of African American parents, lives with her husband and their children for the past 5 years in a 3-bedroom townhouse within easy walking distance to schools and stores, works for 36 hours per week as a warehouse supervisor at Amazon; Phillipa Hudson enjoys enormous support from her husband who works in an accounting office, her fiancé’s parents who live in the same complex they do, and her parents and younger sister who live about a mile away.
Amelia has medical insurance, lives a healthy lifestyle, and eats balanced diet meals. She actively participates in physical activities including soccer. Case Study For Obstetrics Focused SOAP Note Assignment
Significant Family History:
Father – Type 2 diabetes
Mother – Obese
Sibling – No major illness
Children – No major illness
Review of Systems:
General: Fatigue, nausea, breast tenderness; no fever, chills, night sweats; no recent weight gain or loss of significance.
HEENT: Eyes: Negative for visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat
Neck: No pain, injury, or history of disc disease or compression.
Breasts: Positive for breast tenderness, no history of rashes, masses, or lesions.
Respiratory: No shortness of breath, cough, or sputum
CV: Negative for chest pain, chest pressure, or chest discomfort. No history of paroxysmal nocturnal dyspnea, orthopnea, or arrhythmias. No palpitations or edema.
GI: Positive for nausea; negative for abdominal pain or blood. No diarrhea, vomiting, or anorexia.
GU: Negative for sexually STDs and Pap smear; frequent urination; negative for dysuria
MS: No muscle pain, back pain, joint pain, or stiffness
Psych: Denies history of anxiety or depression. Negative for sleep disturbance, delusions, or mental health history. No homicidal or suicidal history.
Neurological: Negative for headache, dizziness, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
Hematologic: No anemia, bleeding, or bruising. No history of clotting difficulties or transfusions
Endocrine: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia. No unintentional weight loss or weight gain.
Allergic/Immunologic: No known allergies to drugs, food, and environment
Reproductive: 1st menses age 12; LMP is 04-04-2022; positive home pregnancy test; Gravida 6 Para 3; negative for contraceptive use; heterosexual; vaginal sex.
OBJECTIVE DATA
Physical Exam:
Vital signs: B/P 112/68 mm Hg, left arm, sitting, regular cuff; P 92 and regular; T 98.6 °F Orally; RR 14 non-labored; Wt: 176 lbs; Ht: 5’4; BMI 30.1 Case Study For Obstetrics Focused SOAP Note Assignment
General: A&O x4, NAD
HEENT: PERRLA, EOMI, oronasopharynx is clear
Neck: Carotids no bruit, jvd or thyromegaly
Chest/Lungs: Negative for wheezing, negative for scattered rhonchi
Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses +2 bilat pedal and +2 radial
ABD: Fundus palpable just above the symphysis pubis
Musculoskeletal: Symmetric muscle development; muscle strengths 5/5 all groups.
Neuro: CN II – XII grossly intact, DTR intact
Diagnostics/Lab Tests and Results:
HCG – Positive
Oral Glucose Tolerance Test – Elevated blood glucose
CBC – Within normal levels
Blood group – A
Rhesus factor – Rh positive
STDs – Negative
Hepatitis B – Negative
Hepatitis C – Negative
HIV – Non-reactive
Urinalysis – +++ glucose, ++ ketone
Urine microscopy – NAD
Rubella – Negative
Fetal ultrasound
Assessment:
Primary Diagnosis:
- Gestational diabetes
The subjective data, objective data, and physical examination results have been used to conclude a primary diagnosis (Ball et al., 2019). Gestational diabetes is characterized by fatigue, nausea, and frequent urination. Positive HCG tests confirm the presence of pregnancy. A complete blood count reveals normal levels of red blood cells indicating the absence of anemia (Mack & Tomich, 2017). The patient also tested negative for hepatitis A and B, HIV, and STDs. The presence of ketones and glucose in urine during urinalysis indicates the presence of gestational diabetes. Oral Glucose Tolerance Test results of elevated blood glucose indicate gestational diabetes mellitus (Mack & Tomich, 2017). Being obese and having a first-degree relative have also increased her risk of gestational diabetes. (Chiefari et al., 2017)Case Study For Obstetrics Focused SOAP Note Assignment.
Differential Diagnosis (DDx):
- Gestational diabetes
- Diabetes type 1
- Diabetes type 2
PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Chiefari, E., Arcidiacono, B., Foti, D., & Brunetti, A. (2017). Gestational diabetes mellitus: An updated overview. Journal of Endocrinological Investigation, 40(9), 899-909. https://doi.org/10.1007/s40618-016-0607-5
Mack, L. R., & Tomich, P. G. (2017). Gestational Diabetes: Diagnosis, Classification, and Clinical Care. Obstetrics and Gynecology Clinics, 44(2), 207-217. https://doi.org/10.1016/j.ogc.2017.02.002 Case Study For Obstetrics Focused SOAP Note Assignment
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.”
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American female). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example: Case Study For Obstetrics Focused SOAP Note Assignment
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
Soc & Substance Hx: Include occupation and major hobbies, family status, vaping, tobacco and alcohol use (previous and current use, how many times a day, how many years), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.
Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation. Case Study For Obstetrics Focused SOAP Note Assignment
Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical).
Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns.
ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.
GENITOURINARY/REPRODUCTIVE: Burning on urination. Pregnancy. LMP: MM/DD/YYYY. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?. sexually active?
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)Case Study For Obstetrics Focused SOAP Note Assignment.
A.
Primay and Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
P.
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?
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Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).
References
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting Case Study For Obstetrics Focused SOAP Note Assignment