SOAP Note Assignment
Name
Department
Course
Date
SOAP Note Assignment
Patient Information
EG, 38 y/o, F, Caucasian
S.
CC: Contraceptive Counselling
HPI
A 38-year-old white female presents for counseling on birth control. The woman wants to start using contraceptives, although her current partner has never had a child. She does not prefer oral contraceptives as she did not follow prescriptions in the past.
SOAP note assignment Current Medications
Vitamin: C
PMH: Migraines, Exercise-induced Asthma and IBS
Surgical History: Tonsillectomy in childhood
Substance History: No use of alcohol, tobacco or any other recreational drugs
Family Health History:
Maternal grandmother alive with Dementia
Maternal grandfather alive with COPD
Mother alive with two conditions: osteopenia and fibromyalgia
The father has basal cell
Her siblings lack any medical complications
Reproductive History:
G5 P5 LC 6
Not interested in conceiving again
Partner has not sired children before.
Objective
Height 5’7 Weight 148(BMI: 23.1) BP 118/72 P68
HEENT: Within normal limits
Lungs/CV: wnl
SOAP note assignmentBreast:
Soft
Fibrocystic changes bilaterally
No masses
Dimpling and discharge absent
Abdomen: +BS, no tenderness
WBSU: wnl except for 1st-degree cystocele
Reproductive:
WBSU: Within the normal limit
1st-degree cystocele
Cervix: Firm, smooth, non-tender, approx. 10 cm
Adnexa: without masses or tenderness
Diagnostic results:
Pap and Pelvis Tests
Pap and pelvic tests are highly recommended before the use of contraceptives. According to (Urrutia et al., 2017), many women avoid pap tests despite their importance in sexual health. The pap test seeks to determine the possibility of cervix cancer before the administration of oral contraceptives. On the other hand, the tests on the effect of Sulphur based contraceptives are to be considered. Finally, a pregnancy test must be conducted as the use of contraceptives during pregnancy is not advised.
BMI Test
In some cases, some contraceptives cause an increase in weight. According to ( San- Juan- Rodriguez et al.,2020), hormonal contraceptives restrict weight gain. The patient may want to consider the effect of each contraceptive on the effect on weight. For instance, she has a BMI of 23.1. BMI above 25 is unhealthy. Therefore, she should decide on the contraceptive from the point of knowledge.
SOAP note assignmentHormone Imbalance Test
Contraceptive pills contain hormones such as estrogen. In addition, it can be caused by hormonal therapy(Aftab & Khan, 2018). The hormones can lead to the formation of fibroids in the uterus if not kept under check. Additionally, contraceptive pills and patches can cause a rise in blood pressure in some women. Consequently, the chances of developing hypertension are on the rise. Therefore she must know the possible side effect of each contraceptive.
Assessment
1
Cluster headaches
Migraines are the premonitory phase of cluster headaches. The condition may not have developed to the prodromal phase. The migraine, a pre-attack syndrome, facilitates the abortive treatment of cluster headaches. (Snoer et al.,2018)
2
Fibrocystic Breast
Fibrocystic changes indicate the development of fibrocystic breast. besides the changes, the presence of lumps, abscesses, and fibroadenomas can lead to the general diagnosis. (Malherbe & Fatima ,2019)
SOAP note assignment
Contraceptive options
Skyla IUD: is a type of LNG-IUD. It is recommended for patients whose spouses are not siring children. Since it works by making mucus in the vagina thick, withdrawal restores fertility almost immediately.
Mirena IUD: it is similar to Syla and works almost identically. In this case, it is highly recommended as the patient does not prefer oral contraceptives. According to (Veisi et al.,2017), Mirena IUD can be used as an effective birth control method by women.
Plan
A pregnancy test will be conducted, and BMI/BP will be sought
Insertion of Mirena IUD will ease the cluster headaches, which are a side effect of oral pills. Besides offering relief, the IUD will prevent pregnancy as well.
Information on the available contraceptive options should be given to the patient. Assuming she chooses Mirena, specific information should be given to the patient. The contraceptive will be effective after a week.
Disposition: The patient will be discharged with annual checkups except for complications.
Reflection: I deliberated the plan with the patient, who concurred with me. To promote her health, breast exams. However, she agreed to remain monogamous; therefore, there is no need to administer STD vaccines.
SOAP note assignment
Questions
What other information do you need?
1
What birth control methods have you used in the past? Why did you stop the method? How many partners were there in the last twelve months (the increase in virginal discharge was due to the insertion of the virginal rings. Having one partner did not affect the volume of discharge)
2
How are your cycles current cycles like? (At your age, you are approaching menopause. Therefore periods tend to have a burning sensation)
3
When was your last gynecological exam, and how were the results? (At your age, you should see the gynecologist after a minimum of three years. Despite the results being healthy, there could have been changes within the five years.)
4
Do your migraines come with auras? (the auras are due to some of the medication for the migraines)
5
What method have you considered? (progestin based pills are the best choice. they do not have migraines as a side effect)
6
What are your next steps? I would help the patient decide on the birth control method while giving her more information on the contraceptives. Additionally, I would advise her to consult if she notices unpleasant side effects from the pills.
7
What teaching would you do? I would educate her on the effects of birth control methods on her health and body at large. Additionally, I would teach her more contraceptive methods she could use
8
What methods would be appropriate for Elaine? The best methods for her would be IUDs with progestin or implants.
References
Aftab, K. U. (2018). CAUSES FOR THE HORMONAL IMBALANCE AMONG YOUNG FEMALE IN HAIL REGION. International Journal of Biological Sciences and Research, 1(3), 118-122.
Malherbe, K., & Fatima, S. (2019). Fibrocystic breast disease.
San-Juan-Rodriguez, A., Bes-Rastrollo, M., Martinez-Gonzalez, M. A., Martín-Moreno, J. M., Rico-Campà, A., & Gea, A. (2020). Oral contraceptives use and development of obesity in a Mediterranean cohort: the sun (Seguimiento Universidad de Navarra) project. International Journal of Obesity, 44(2), 320-329.
Snoer, A., Lund, N., Beske, R., Jensen, R., & Barloese, M. (2018). Pre-attack signs and symptoms in cluster headache: Characteristics and time profile. Cephalalgia, 38(6), 1128-1137.
Urrutia, M. T., Araya, A., & Jaque, M. F. (2017). Why do Chilean women choose to have or not have Pap tests?. Journal of Obstetric, Gynecologic & Neonatal Nursing, 46(1), e3-e12.
Veisi, F., Zangene, M., Rezavand, N., Jalilian, N., & Hemmati, M. (2017). Effects and Consequences of the levonorgestrel in women using IUD. Journal of Clinical Research in Paramedical Sciences, 6(2).
Question
Elaine Goodwin is a 38-year-old G5 P5 LC 6 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.
• Height 5’ 7” 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.
SOAP note assignment