SOAP Note For Discussion Of Contraceptive Options
SOAP Note For Discussion Of Contraceptive Options
Patient Information
Initials: E.G.
Age: 38 Years
Sex: female
Subjective Data
Chief Complain: discussion of contraceptive options
History of presenting Illness: E.G., 38 years old G5P5006, presented to the clinic to discuss some of her contraceptive options. She states she is not interested in having more children, but her new partner has never fathered a child. SOAP Note For Discussion Of Contraceptive Options
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Current Medications
Vitamin C
Allergies
No known drug allergies.
Past medical History
Exercise-induced asthma, migraines, and IBS.
Social and substance History
Denies alcohol consumption, cigarette smoking, and recreational drug use.
Family History
She has two siblings. Both are alive and well without medical problems.
The maternal grandmother is alive and has dementia. Maternal grandfather is alive with COPD.
Paternal grandparents are both deceased secondary to an automobile accident.
Her mother is alive and has osteopenia, whereas her father is alive and has a history of skin cancer( basal cell).
Surgical History
Tonsillectomy as a child.
Objective Data
General: she is in a fair general condition
Vital signs: BP 118/72mm/hg PR 68beats/minute, height 5’7’ weight 148, BMI 23.1kg/m2.
Physical examination
Breast: soft, bilateral fibrocystic changes without masses, dimpling, or discharge.
Abdomen: soft, bowel sounds are present, and there is no tenderness.
VVBSU: no abnormal detection except 1st-degree cystocele
Cervix: firm, smooth parous, and without congenital malformation.
Uterus: R.V. mobile, non-tender, approximately 10cm.
Adnexa: has no masses or tenderness. SOAP Note For Discussion Of Contraceptive Options
Diagnostic tests
PDT: rule out pregnancy.
Lipid profile: assess the risk of atherosclerosis.
Full hemogram: check the hemoglobin level and rule out anemia
Coagulation profile: evaluate the bleeding risk.
Assessment
Cystocele (N81.10): mainly occurs when the bladder shifts from its usual position in the pelvic cavity to the vagina walls. Some of the most common causes include; a chronic cough, pregnancy, vaginal birth, straining with bowel movement, obesity, and repeated heavy lifting (Makajeva J; Watters C; Safioleas P, 2022). In addition, the physical examination of E.G. revealed a cystocele common in multiparous.
Stress incontinence (N39.3) is the unintentional passage of urine under pressure. The pelvic floor mainly supports the urethra and bladder (Lugo & Riggs, 2022). Stress incontinence occurs when it gets excessively stretched, weakened, or damaged, especially during pregnancy and childbirth.
UTI (N39.0): incomplete emptying of urine often predisposes patients to UTI. One of the most common culture Media that encourages bacterial growth is retained urine (Bettcher et al., 2021)SOAP Note For Discussion Of Contraceptive Options. Patients with cystoceles have an increased risk and share similar signs and symptoms of UTIs.
Additional questions
- Inquire when the last normal period was? This is to rule out the likelihood of pregnancy as one cannot begin contraception with a growing fetus.
- Does the patient experience urinary symptoms such as; incontinence, urgency, increased frequency, or urine leakage while coughing or laughing, given her parity?
- Does the patient have a history of family planning use? If yes, which ones specifically?
- What is her menstrual History? Include the age at which she attained menarche, cycle regularity, and associated symptoms.
- Since the patient has exercise-induced asthma and IBS, ask what medications she is currently on.
- List the findings on the review of systems to help include or rule out a differential diagnosis.
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References
Bettcher, C. M., Campbell, E., Petty, L. A., Rew, K. T., Zelnik, J. C., Lane, G. I., R. Van Harrison, Proudlock, A. L., & Rew, K. T. (2021, May). Urinary Tract Infection. Nih.gov; Michigan Medicine University of Michigan. https://www.ncbi.nlm.nih.gov/books/NBK572335/
Lugo, T., & Riggs, J. (2022, May 2). Stress Incontinence. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539769/
Makajeva J;Watters C;Safioleas P. (2022, January 10). Cystocele. https://pubmed.ncbi.nlm.nih.gov/33231973/ SOAP Note For Discussion Of Contraceptive Options
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: SOAP Note For Discussion Of Contraceptive Options
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)SOAP Note For Discussion Of Contraceptive Options, 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.
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. SOAP Note For Discussion Of Contraceptive Options
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? SOAP Note For Discussion Of Contraceptive Options
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).
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. SOAP Note For Discussion Of Contraceptive Options
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?
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)SOAP Note For Discussion Of Contraceptive Options.
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.
Elaine Goodwin is a 38-year-old G5P5006  presenting to your clinic today to discuss contraceptive options.  She states that she is not interested in having more children but her new partner has never fathered a child. Her medical history is remarkable for exercise-induced asthma, migraines, and IBS. Her surgical history is remarkable only for tonsils as a child. Her social history is negative for alcohol, tobacco, and recreational drugs.  She has no known drug allergies and takes only vitamin C. Hospitalizations were only for childbirth. Family history reveals that her maternal grandmother is alive with dementia, while her maternal grandfather is alive with COPD. Her paternal grandparents are both deceased due to an automobile accident. Her mother is alive with osteopenia and fibromyalgia, and her dad is alive with a history of skin cancer (basal cell). Elaine has one older sister with no medical problems and one younger brother with no reported medical problems. SOAP Note For Discussion Of Contraceptive Options
• Height 5’ 7â€â€¯Weight 148 (BMI 23.1), BP 118/72 P 68 
• HEENT:  wnl 
• Neck: supple without adenopathy 
• Lungs/CV: wnl 
• Breast: soft, fibrocystic changes bilaterally, without masses, dimpling or discharge 
• Abd: soft, +BS, no tenderness 
• VVBSU: wnl, except 1st degree cystocele 
• Cervix: firm, smooth, parous, without CMT 
• Uterus: RV, mobile, non-tender, approximately 10 cm, 
• Adnexa: without masses or tenderness 
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Please POST your FOCUSED SOAP NOTE with your differential diagnosis. Include the additional questions you would ask the patient. Be sure to include an explanation of the tests you might recommend, ruling out any other issues or concerns and include your rationale. Be specific and provide examples. Use your Learning Resources and/or evidence from the literature to support your explanations SOAP Note For Discussion Of Contraceptive Options