Focused Soap Note For Womens Health Discussion
Focused Soap Note For Womens Health Discussion
Women’s Health
Bio Data
Patients Initials: S
Age: 24 years
Gender: female
Race: Caucasian
Subjective Data
Chief complaint: post-coital bleeding and sore throat.
History of presenting illness: miss S 24-year-old Caucasian female, presented to the clinic for her regular care. She reports that she has been having post-coital bleeding for the last six weeks and has had a sore throat for the past three weeks. She also had a history of fever for a day or two but was relieved by Tylenol Focused Soap Note For Womens Health Discussion.
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Current medications
She is currently not on any medications
Allergies
No known food-drug allergy
Medical and surgical history
No remarkable findings
Family history
Non-contributory
Social History
Remarkable for cigarette smoking ½ packs per day since the age of 14. Consumes ETOH only on weekends, 6-8 hard liquor/daily, and marijuana smoking Focused Soap Note For Womens Health Discussion.
Gynecological History
She attained menarche at 13 years. The cycle is after every 28-32 days, lasting 4-6 days and using three tampons per day. She reports cramping during her menses, for which she takes pamprin.
Health Maintenance
She jogs 3-4 times per day for one week. Wears seatbelts when in the car and occasionally uses sunscreen.
Objective data
Physical Examination
Vital signs: BP 112/64mm/hg PR 68beats/min, temperature 97.8 height 5’6 and weight 118lbs, BMI 19.04kg/m2
HEENT: the head is normocephalic, hearing is intact bilaterally, no eye discharge, and the septum is not deviated. However, there is bilateral anterior cervical adenopathy and throat appears reddened.
Lungs: the lungs are clear bilaterally on auscultation.
Cardiovascular: regular sinus rhythm without murmur or gallop.
Abdomen: soft, non-tender and normal liver span.
Breasts: bilateral fibrocystic changes. No redness, dimpling, masses or discharge, no adenopathy, and bilateral nipple piercing Focused Soap Note For Womens Health Discussion.
VVSBU: no abnormal findings. Yellow discharge that is slightly frothy from the cervix. Clitoral piercing noted.
Cervix: friable, has some petechial, and no cervical movement observed.
Uterus: mid-mobile and non-tender.
Adnexa: has no masses or tenderness.
Perineum: intact, with no abnormal detections.
Rectum: no abnormal findings.
Extremities: full range of movement skin is clear, no edema, and reflexes 1+.
Neurological: cranial nerves are grossly intact.
Diagnostic tests
CBC:to check for evidence of leukocytosis to rule out infection. Check the hemoglobin levels to rule out anemia with a history of bleeding.
Endo-cervical swab: take the yellowish discharge for microscopy, culture, and sensitivity.
Throat swab: for microscopy culture and sensitivity to identify the causative organism.
STD screening: rule out sexually transmitted infections.
Assessment
Primary diagnosis
Chlamydia is caused by chlamydia trachomatis and is mainly transmitted through; oral, vaginal, or anal sex. In women, the most common anatomical site is the cervix. Other urogenital infections include; urethritis, pelvic inflammatory disease, and lymphogranuloma venerum. In men, it causes prostatitis and epididymitis. Extra genital infections include pharyngitis, conjunctivitis, reactive arthritis, and proctitis (Mohsen et al., 2022)Focused Soap Note For Womens Health Discussion. Clinical presentations include; post-coital bleeding, intermenstrual bleeding yellowish per vaginal discharge, dyspareunia, fever, and abdominal pain.
Additional questions
A sexual history is essential as it allows for counseling and sharing appropriate information about behaviors that may increase the risk of getting STIs (Savoy, 2020). Ask about the number and gender of sexual partners to help in the risk assessment of sexually transmitted infections. This will help understand a person’s sexual behavior to adequately support them (Garcia MR; Wray AA, 2022). Ask if the patient has a previous history of STIs. According to Barrow et al. ( 2020), a previous history of an STI puts the patient at a greater risk now. What mode of sexual contact does she mainly engage in? According to Brookmeyer et al. (2020)Focused Soap Note For Womens Health Discussion, enquiring about the sexual practices guides in assessing the patient’s risk, determining appropriate testing, identifying the relevant anatomical site for specimen collection, and coming up with risk-reduction strategies. A review of systems is essential to identify any presenting complaints that might not have been captured in the history of presenting illness.
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References
Barrow, R. Y., Ahmed, F., Bolan, G. A., & Workowski, K. A. (2020). Recommendations for Providing Quality Sexually Transmitted Diseases Clinical Services, 2020. MMWR. Recommendations and Reports, 68(5), 1–20. https://doi.org/10.15585/mmwr.rr6805a1
Brookmeyer, K. A., Coor, A., Kachur, R. E., Beltran, O., Reno, H. E., & Dittus, P. J. (2020). Sexual History Taking in Clinical Settings: A Narrative Review. Sexually Transmitted Diseases, 48(6), 393–402. https://doi.org/10.1097/olq.0000000000001319
Garcia MR;Wray AA. (2022, May 8). Sexually Transmitted Infections. https://pubmed.ncbi.nlm.nih.gov/32809643/
Mohseni, M., Sung, S., & Takov, V. (2022, April 30). Chlamydia. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537286/
Savoy. (2020). Sexual Health History: Techniques and Tips. American Family Physician, 101(5). https://pubmed.ncbi.nlm.nih.gov/32109033/
To prepare: Focused Soap Note For Womens Health Discussion
- By Day 1 of this week, you will be assigned to a specific case study 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 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 your Discussion. Complete a FOCUSED SOAP note and critically analyze this and focus your attention on the diagnostic tests. Please post your FOCUSED SOAP note. This information will help you develop your differential diagnosis and additional questions
By Day 3
Please POST your FOCUSED SOAP NOTE and post your primary diagnosis. Include the additional questions you would ask the patient and explain your reasons for asking the additional questions. Then, explain the types of symptoms you would ask. Be specific and provide examples. (Note: When asking questions, consider sociocultural factors that might influence your question decisions.)Focused Soap Note For Womens Health Discussion
Based on the preemptive diagnosis, explain which treatment options and diagnostic tests you might recommend. Use your Learning Resources and/or evidence from the literature to support your recommendations.
Case Study 2
Case Study: STI Investigation
Susan Lang is a 24-year-old Caucasian female presenting to the clinic for regular care. She works full-time as an administrative assistant, and relates she loves her job. She has no medical or surgical history, takes no medication, and has no allergies. Family history is non-contributary. Social history is remarkable for cigarette smoking at a rate of ½ packs per day (PPD) since age 14, / ETOH only on weekends, 6-8 hard liquor/ daily, and marijuana smoking. Gyn history is onset of menses age 13, menses every 28-32 days, lasting 4-6 day and using 3 tampons daily. She has some cramping during her menses for which she takes otc Pamprin. She jogs 3-4 times a week, wears seatbelts when in the car, and “occasionally” uses sunscreen. Susan relates she has been having some postcoital bleeding for the past 6 weeks and has had a sore throat for past 3 weeks. She did have a fever for a day or two, but Tylenol took care of it and she thought it was allergies. Focused Soap Note For Womens Health Discussion
Susan’s vital signs are taken and were temperature 97.8, pulse 68, BP 112/64, height 5’6” and weight 118 lbs. (which was the same as last year). BMI 19.04
- HEENT: WNL except some anterior cervical adenopathy bilaterally, and throat appears reddened.
- Lung: clear to auscultation
- CV: regular sinus rhythms without murmur or gallop
- Abd: soft, non-tender, liver normal,
- Breasts: fibrocystic changes bilaterally, no masses, dimpling, redness or discharge, no adenopathy, and bilateral nipple piercings.
- VVBSU: wnl, slight frothy yellow discharge by cervix, clitoral piercing noted
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- Cervix: friable, some petechia no cervical motion tenderness.
- Uterus: mid mobile, non-tender
- Adnexa: without masses or tenderness
- Perineum: wnl
- Rectum: wnl
- Extremities: full rom, skin clear, no edema, reflexes 1+.
- Neurological: CN II-12 grossly intact. Focused Soap Note For Womens Health Discussion