Practicum – Focused SOAP Note and Time Log.

Assignment: Practicum – Focused SOAP Note and Time Log Select a patient that you examined during the last four weeks, (55 years old, with an ovarian cyst) . With this patient in mind, address the following in a Focused SOAP Note: Subjective: What details did the patient provide regarding or her personal and medical history?

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Objective: What observations did you make during the physical assessment? Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses.Practicum – Focused SOAP Note and Time Log. List them from highest priority to lowest priority. What was your primary diagnosis and why? Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Reflection notes: What would you do differently in a similar patient evaluation? important to address the following: CC Pertinent positives and negatives in the ROS Pertinent PMH, SH,and FH Allergies Vital Signs Physical Exam Diagnostic test results Assessment with 3 priority diagnosis Medications new and d/c\’d Alternative therapies if appropriate Diagnostic tests ordered with time frame Referrals or consultations if appropriate Follow up interval Reflection should include the following: What did I learn form this experience? Any ah-ha\’s. What would you do differently? What additional data would you have gathered? What additional elements of the exam would you have done? Do you agree with your preceptor based on the evidence?Practicum – Focused SOAP Note and Time Log.

Focused SOAP Note and Time Log

Patient Information:

Initials:   J.C Age: 55 Sex: Female Race: Caucasian

SUBJECTIVE:

Chief Complaint (CC): “Pelvic pain, bloating in the abdomen”

History of Present Illness (HPI): 55-year-old Caucasian, married, female presents to the clinic today with complaints of right sided pelvic pain and abdominal bloating. She mentions that it startedfive months ago and she describes the pain as stabbing pain which can be debilitating. She reports having lost appetite for one month which has resulted in her losing 22 pounds. She is also concerned about her urination, which has become more frequent than normal.Practicum – Focused SOAP Note and Time Log.

Onset: 5 months ago

Location: pelvic region

Duration: 5 months

Characteristics:  stabbing pain, abdominal bloating

Aggravating Factors: None

Relieving Factors: heating pad and Ibuprofen 600mg

Severity: 8/10

Current Medications:

Ibuprofen 600mg every 4-6 hours as required for relieving pain

Allergies: Penicillin

Past Medical History (PMH):, PCOS

Past Surgical History (PSH):Caesarean section

Personal/Social History: J.C is married, and an employed woman. She resides in her hometown with her husband and two of her children. She denies use of alcohol, tobacco abuse or illicit substances.

Family History: Father (deceased): stroke. Mother (deceased): kidney failure. Three of her siblings are alive and in good health.Practicum – Focused SOAP Note and Time Log.

OB/GYN History:

Menstrual History:

Age at menarche – 15

LMP – 2006

Menstrual Pattern: irregular cycle

Menopause:

2006

Contraception:

N/A

Cervical & Vaginal cytology:

Most recent pap – 7/2018

History of abnormal Pap smear – no history

Infections:

No history of STIs or PID

Sexual History:

Heterosexual, mutually monogamous relationship

Denies experiencing sexual abuse and assault

Review of Systems:

General: Reported weight loss, reduced appetite. No fever, fatigue, or chills.Practicum – Focused SOAP Note and Time Log.

Head: Denies migraine, headache, and dizziness.

 Eyes: no vision problems

 Chest: chest pain, cough or SOB

 Heart: No palpitation or irregular heartbeat

 Breast: No breast pain, nipple discharge, no inflammation, or erythema.

Gastrointestinal: Reports lower abdominal discomfort. Denies vomiting and nausea. No constipation and Diarrhoea

 Urinary: Reports urinary frequency. No history of UTI

Musculoskeletal: no joint or muscle pain. Denies pain radiation.

Skin: No skin changes like itching, dryness or rashes

Psychiatric: No mental issues; anxiety, depression or mood changes.

Neurological: Denies seizures, weakness or dizziness.

Endocrinological: No cold or heat intolerance, no thyroid or diabetes problem.

Immunologic: No immune deficiencies or recurring infections.

Hematologic: No cancer,anaemia, bleeding problem or blood transfusion.

Lymphatics: no history of cervical lymphadenopathy or Splenectomy

Allergies: No rhinitis,hives,eczema, or asthma.

OBJECTIVE:

Vital Signs:  Ht. 5’8” Wt. 132lbs, BMI = 20.1, T-max 89.5, BP 103/67, pulse 77, respirations 15, o2, saturation 99% on RA.

Physical Exam:

General: Well-nourished, clean, well-appearing woman

HEENT: PERRLA clear ears, no rhinorrhea, or cervical lymphadenopathy

Skin: Intact, no rashes or dryness

Respiratory: Lungs unilateral, and no clear to auscultation. No wheezing, rales, or rhonchi. No sputum production or cough

Cardiovascular: regular rate and rhythm

Gastrointestinal:Nontender, soft, no changes in bowel movements

Genital/Rectal: normal external genitalia, pink, no masses, trauma, or lesions. Hair is evenly distributed. Urethra: midline, no irritation, Vagina: healthy pink mucosa, clear discharge, no gross lesions noted.  Cervix: pink, no lesions, closed OS. No cervical motion or tenderness. Uterus: small, no palpation or tenderness, no masses, freely movable.Practicum – Focused SOAP Note and Time Log.

Genitourinary: No problems noted

Neurological: no seizures, or focal deficits. AOx4, moves all extremities without tremors. Clear speech, appropriate communication.

Psychiatric: appropriate, cooperative, calm

Musculoskeletal: normal ROM, no joint pain or muscle aches

Labs/Diagnostic Tests & Results:

Transvaginal US – 2.4×1.8x2cm and 1.3x1x1.2 cm cysts noted on L ovary, normal uterus (no fibroids)

Complete Blood Count – to be completed as outpatient

Urine test- no UTI found

ASSESSMENT:

Primary Diagnosis –Ovarian Cyst

Ovarian cysts are fluid or semi-fluid tissue that occurs from the ovaries. The majority of patients that have ovarian cysts do not present any symptoms. However, there are symptoms such as pelvic pain, abdominal bloating, and changes in bowel movement patterns, tachycardia, and heartburn in women with ovarian cysts (Grabosch, 2018). The patient is positive for pelvic pain and bloating. Other manifestations include loss of appetite and dysuria, which the patient reported. An ultrasound is a key test for the examination of ovaries and assessment of the presence of cysts or the enlargement of the ovaries.Practicum – Focused SOAP Note and Time Log.

Differential Diagnosis #2 – Uterine Fibroids

Uterine fibroids present as uterine tumors of smooth muscle root. This condition usually leads to pelvic pain, irregular uterine bleeding, and often dysuria symptoms. The patient is positive for pelvic pain and dysuria. Fibroids are assessed through ultrasound, pelvic examination, and other screening (Mutch&Biest, 2019). It is therefore ruled out because the results of the ultrasound are negative.

Differential Diagnosis #3 – Pelvic Inflammatory Disease (PID)

PID pain and inflammation occur in the pelvic organs, such as the fallopian tubes, the ovaries, and the uterus. PID is the common term for the infection of ovaries, oviducts, and surrounding organs, which may present as chronic, subacute, occasional, or recurring (Brunham et al. 2017). Numerous PID ailments are triggered by pathogens such as N Gonorrhoea and Chlamydia trachomatis can even be microbial or contagious. PID is likely, but it is unlikely to accept any single differential outcome. The patient has no known history of PID, no past sexually transmitted infections (STIs), and no changes in vaginal discharge. The PID is therefore ruled out.Practicum – Focused SOAP Note and Time Log.

PLAN:

Treatment / Management Plan and Follow up Care

An ovarian cyst is chosen as the key diagnosis because diagnostic, laboratory and physical testing eliminated other potential alternative diagnoses, so the treatment/management strategy for the disease may focus on the patient’s wishes or priorities. Watchful waiting will be implemented for this patient. She will wait for one month to re-examine the cysts through ultrasound (Kabir, 2016).

Medication

Medications will assist in relieving pelvic pain. The patient will continue with Ibuprofen 600 mg q6 hours to relieve pain and discomfort. The patient will be asked to follow up every one month for re-evaluation of management and treatment, as well as for re-evaluation of cysts in the ovary. The efficiency of the treatment will be assessed and treatment changes will be made, if necessary. RTC will be administered if pain worsens or not controlled by ibuprofen.Practicum – Focused SOAP Note and Time Log.

 Alternative Therapy

The most appropriate alternative therapy for this patient will be to take ginger tea to help relieve pain and reduce inflammation. Ginger tea is a herbal alternative for natural pain relief and bloating. It also possesses anti-carcinogenic and antioxidant properties. Research has shown that ginger stops the growth of ovarian cancer cells, meaning that dietary consumption of ginger could be used in the treatment of ovarian cysts (Medihospital.com.cy, 2020).Practicum – Focused SOAP Note and Time Log.

Health Promotion

The patient will be given age-appropriate education services on risk factors, causes, care, and management of ovarian cysts. She will be advised that the illness will be handled, and they should not worry, but comply and stick to medications and treatments. Patients should be informed about the likelihood of other health problems relating to ovarian cysts, such as ovarian cancer (Kim et al., 2016). Moreover, she will be told of the likelihood of depression and anxiety related to the disease, but priority should be given to the importance of obtaining mental health counseling. Services will be offered to the individual to support her sustain a fruitful life. No referral was given at this point because there was no specifically established need for referral.Practicum – Focused SOAP Note and Time Log.

Reflection: 

I am finding that this clinical practice is informative. I didn’t think I would consider it, and I am steadily building a greater understanding of the specific reasons behind the numerous treatment methods that aid in the management of ovarian cysts. These treatment options will focus on enhancing the patient’s everyday efficiency. I also got to learn that there is an alternative therapy which is drinking ginger tea, which is aimed at alleviating pain and reducing inflammation. Practicum – Focused SOAP Note and Time Log.

I would not have made a different decision because I believed I had carried out a detailed examination of the patient in conjunction with my preceptor, regarding the patient’s health situation, therefore I carried out the appropriate clinical practice in collaboration with my preceptor to obtain a reasonable primary and differential diagnosis and a care plan for the patient’s health issue.Practicum – Focused SOAP Note and Time Log.