Endometrosis notes
I need 100% plagiarism free paper, the writer has to be a medical professional or a nurse who knows whats going on. This is a soap note for a patient I will upload and then need to change every thing on it and updated so when i turn it in to turnitin i get very low plagarism on it.
please add different references as the current one is used all ready and will come up in turnitin. WARNING: IF ITS PLAGARIZED I WILL ASK FOR MONEY BACK AND GIVE BAD REVIEWS.
SOAP NOTE
Name: PK
Date: 8/7/19
Time: 1234
Age: 35
Sex: F
SUBJECTIVE
CC:
PK is a 35 year-old Caucasian woman who presents in the hospital complaining about lower abdominal pain for the past 3 days.
HPI:
For the last three days, PK reports that her lower abdominal pain radiates from the lower back. She has been experiencing a non-ending pain whereby when leaning forward, the pain reduces, but when she is removing the bowels the pain exacerbates. She states every day she takes OTC Ibuprofen though the relief is minimal. The pain makes her feel uncomfortable throughout the day. Previously, her menstrual cycle is normal though the flow is heavy and menstrual cramps. She expects her period two days from now. Unusual with other days, she states she feels more fatigued and reports significant deep dyspareunia.
Medications:
Since the pain began, 6 hours ago, she has been taking Ibuprofen 800mg
PMH
Allergies:
NKFA
Tramadol pruritus, rash
PCN anaphylaxis
Medication Intolerances:
Refutes
Chronic Illnesses/Major traumas:
Refutes
Hospitalizations/Surgeries:
Hysterectomy, and
2 caesarian delivery
Family History
Mother hysterectomy age 56, endometriosis
Father had asthma since childhood, smoker, and hypertension.
Social History:
Denies any history of anxiety or depression
Every evening takes 1-2 glass of red wine but never exceeds 5 glasses
She has been working in the ICU RN for the last 2 years
Her life is very busy with full of stress
Refutes taking any drug and tobacco
Married, lives with husband and two dogs
General: born and raised in Newton Grove, NC.
Marital status: Married
Living situation: a busy life where she stays with her husband.
Children: none
Occupation: a nurse
Leisure Patterns: walking in the woods with her dog
Social habits: does not smoke, takes 1-2 glass of wine. Does not exercise.
Spirituality: Christian
Nutrition: Sleep Patterns: rarely eats fast foods. Prepares her balanced diet at home.
ROS
General
Denies fatigue or malaise, chills, night sweats, any weight changes.
Cardiovascular
Denies chest pain, irregular heartbeats, palpitations, pressure or chest pain. Denies lower extremity edema. No history of heart immune, anemia, CAD, or hypertension.
Skin
No rashes or torso, reports round and red to pink area of hair loss.
Respiratory
Denies shortness of breath, cough, wheezing, and difficulty breathing on exertion.
Eyes
Vision 20/20 in both eyes with contact lenses, reports light sensitivity with headache, denies any trauma, familial disease or glaucoma.
Gastrointestinal
Denies constipation, diarrhea, nausea, acid reflux, or heartburn. Reports lower abdominal pain.
Ears
Denies hearing difficulty, earaches, vertigo, or tinnitus.
Genitourinary/Gynecological
Denies past hx of STLs, urinary incontinence, urgency frequency, dysuria, or hematuria, deep dyspareunia.
Nose/Mouth/Throat
Denies bleeding gums, sores, mouth/jaw pain, congestion, rhinorrhea, or oral lesions.
Musculoskeletal
Denies joint pain, muscle stiffness or weakness. She reports does not have restriction of range of motion.
Breast
No nipple discharge, rash or swelling. Denies recent breast changes, performs self-breast exams.
Neurological
Denies dizziness, numbness, tingling, fainting, or vertigo.
Heme/Lymph/Endo
Reports negative HIV status. No thyroid enlargement or tenderness, no polyuria, no polydipsia, no heat or cold intolerance. Denies increase thirst, or night sweats.
Psychiatric
Denies depression, anxiety or depression.
OBJECTIVE
Weight187lbs BMI 20
Temp 97.3 F
BP 124/77
Height 67
Pulse 92
Resp 18
General Appearance
Well nourished, well groomed appears age appropriate
Skin
No lesions, moles or itching. Moist and pink without rash or erythema.
HEENT
Atraumatic, normocephalic. Neck supple, no JVD.
Cardiovascular
No chest pain, palpitations or extremity edema; no pain with walking
Respiratory
No signs of respiratory distress. No wheezing, rales or rhonchi. Clear to auscultation.
Gastrointestinal
NO hepatosplenomegaly. BS active in all 4 quadrants. Abdomen round, soft, and non-distended.
Breast
Nipples without discharge. Symmetric and smooth without masses.
Genitourinary
External genitalia without abnormalities or lesions, perineum non-inflamed, normal hair distribution. Vaginal walls are moist and pink and smooth. Uterus fixed non-tender and retroverted. Cervix firm, mobile with positive cervical motion tenderness. Bilateral adnexal masses with tenderness.
Musculoskeletal
Full ROM seen in all 4 extremities as patient moved about the exam room.
Neurological
Alert and answers questions clearly and follows commands appropriately. Reflexes are 2+ and symmetric with plantar reflexes. Rapid alternating movements intact. Light touch, position, and vibration intact
Psychiatric
Patient is not suicidal. Demonstrates appropriate cognition, judgment and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination.
Lab Tests
STD panel negative
Urinalysis WNL
Wet amount negative
Urine for pregnancy test negative
CBC – Hemoglobin 9 g/dl, Hematocrit 33.1%
Special Tests
None ordered today.
Diagnosis
Diagnosis:
1. N80.9: Endometriosis
Differentials:
1. Appendicitis
2. Pelvic inflammatory disease
Plan/Therapeutics
Plan:
Diagnostic: No tests needed at this time
1) Transvaginal Ultrasound to report the presence or absence of structural abnormalities, an ultrasound will be recommended, which will remove other pathology, and somewhat identify the pressure of endometriosis seen as cysts with no vascularity. According to Goolsby & Grubbs (2018), this should be termed as the first-line imaging technique not just it helps in high diffusion, availability but it is cheap and patient acceptability.
2) Rx Percocet 5/325 1-2 tablets every 6 hours as needed for pain (40 pills, no refills) as NSAIDs are not currently managing pain (Ashrafi et al., 2016).
3) Referral to OB/GYN endometriosis diagnosis is done using Laparoscopy with biopsy which is considered the gold method of surgery though it requires anesthesia. Additionally, at this particular moment, it would be inappropriate to initiate hormonal contraceptives as the patients desire. To remove as much as endometriosis as possible, the patient will fall the victim for conservative surgery, while taking care of her uterus and ovaries from damage can be done through laparoscopy (Harada, 2013). For her to become pregnant, insemination of fertility medication or IVF are needed and consult from an OB/GYN would be necessary.
4) Education:
Should avoid alcohol while on Narcotic pain prescription
Application of heat to lower abdomen/back may offer pain relief
Pain symptoms could be reduced by exercise. Recommendation of 30 minutes cardio workout.
Harada (2013) states that the risk of endometriosis tends to increase when a person takes alcohol. Moreover, alcohol cessation while trying to conceive is recommended.
I would encourage the patient that, those with endometriosis conditions have a high risk of being infertile and managing the disease may improve chances of conceiving.
5) Precautions/Follow Up
Make sure to keep appointments concerning OB/GYN referral
Follow up in 1 year for an annual exam is required
Return to the hospital or go to the emergency room if pain changes, worsens, and/or does not improve with prescribed pain drugs.
.
Assessment
This clinical presentation is highly suggestive of endometriosis. The way the patent experiences the pain and its onset before the start of her menstrual period along with reports of gradually worsening pelvic menstrual cramping, painful bowel movement, as well as irregular menstrual cycles with the extended and heavy flow all happen with this disease progression. Endometriotic implants on posterior peritoneum, ovaries, and uterus and rectosigmoid colon would explain to lower abdominal/back pain, heavier periods and painful defecation. As per the recent research, having one or more relative, regular alcohol intake and nulliparity early menarche with endometriosis considerably increases a womans odds of developing endometriosis (Said & Azzam, 2014).
References:
Ashrafi, M., Sadatmahalleh, S. J., Akhoond, M. R., & Talebi, M. (2016). Evaluation of risk factors associated with endometriosis in infertile women.International journal of fertility & sterility,10(1), 11.
Goolsby, M. J., & Grubbs, L. (2018).Advanced assessment interpreting findings and formulating differential diagnoses. FA Davis.
Harada, T. (2013). Dysmenorrhea and endometriosis in young women.Yonago acta medica,56(4), 81.
Said, T. H., & Azzam, A. Z. (2014). Prediction of endometriosis by transvaginal ultrasound in reproductive-age women with normal ovarian size.Middle East Fertility Society Journal,19(3), 197-207.
