Endometriosis SOAP Note Discu

Case 3

Endometriosis SOAP Note

Name: AJ

Date: 16/9/2021

Age: 40

Time: 1300

Sex: Female

SUBJECTIVE

CC: AJ is a 40-year-old African-American female admitted to the hospital after complaining about lower abdominal pains for the past 72 hours.

HPI: For the past 72 hours, AJ accounts that her lower abdominal pains radiate from her backside. According to the patient (AJ), she started experiencing endless pains whereby when she tries to lean forward, the pains subside, but when she removes the bowels, the pains exacerbate. She says that she does take Over the Counter (OTC) Ibuprofen daily, although the relief does not last for long. The pains often make her upset and uneasy all through the day. Before this, her menstrual cycle was somewhat regular, although she occasionally had heavy flows accompanied by menstrual cramps. AJ is expecting her monthly periods in three days’ time. Unlike other times, she notes that she is relatively drained and weary and experiences painful intercourse.

Medications: since she started experiencing the pains, 8-hours ago, she has been taking Ibuprofen 650mg.

PMH

Allergies

  • No Known Food Allergy
  • Ultram- itching, rashes

Medication Intolerance: Denies

Chronic Conditions: Denies

Major surgical procedures:

3 Caesarian deliveries

Family History

  • Mother61 hysterectomy, endometriosis
  • Father – 65 asthmatic, hypertensive, heavy drinker

Social History

  • Denies being anxious or depressed
  • Takes 3 to 4 glasses of red wine daily
  • AJ has been working in the Intensive Care Unit for 24 months
  • She lives a busy life and is often stressed
  • Denies being a smoker and drug addict
  • Married, stays with her husband and three kids

General: born and raised in Tampa Bay Area, Florida

Marital status: Married

Living situation: Has a busy lifestyle

Children: three

Occupation: Nurse

Leisure Patterns: Reading, Jogging

Social habits: Does not smoke, takes 3 to 4 glasses of wine daily, does not go to the gym.

Spirituality: Muslim

Nutrition: Does not eat red meats

ROS

General: The patient is not fatigued. She does not complain of an underlying sickness, night sweats, or wariness.

Skin: No visible rashes

Eyes: Sensitive to light, refutes trauma, ancestral diseases, or eye conditions.

Ears: Refutes hearing difficulties, earache, light-headedness, or tinnitus

Nose/Mouth/Throat: Refutes bleeding gums, sores, or jaw pains

Cardiovascular: Refutes chest pains, irregular heartbeats, palpitation. Does not suffer from anemia, Coronary Artery Disease (CAD), or hypertension

Respiratory: Refutes short breath, coughs, panting, and difficulty breathing

Gastrointestinal: Refutes constant constipation, diarrhea, vomiting, acid refluxes, or heartburns. Complains of sharp lower abdominal pains.

Gynecological: Refutes history of Sexually Transmitted Infections (STIs), urinary incontinences, or hematuria

Musculoskeletal: Refutes joint pains

Neurological: Refutes faintness, numbness, or vertigo

Lymph/Endo: Refutes any abnormal bleeding, no thyroid enlargements

Psychiatric: Refutes being depressed or anxious

OBJECTIVE

Weight: 177lbs

BMI: 21

Height: 5’8’’

Temperature: 98.1 F

BP: 123/68

Pulse: 91

Resp: 17

General appearance: Well nurtured, adequately presented.

Skin: No evident lesion, moist.

Head, Eyes, Ears, Nose, Throat (HEENT): Atraumatic, Normocephalic, No Jugular Vein Distention

Cardiovascular: No chest pains or palpitation

Respiratory: No sign of respiratory distresses. Does not wheeze

Gastrointestinal: Both liver and spleen are of the correct and normal sizes. Round, softer abdomen

Breast: No discharge from either nipple

Neurological: the patient appears alert and can answer questions in a clear manner. She can follow instructions correctly.

Psychiatric: The patient does not appear suicidal. Shows appropriate cognitive, judgment, and reasoning abilities. Does not show any abnormal behavior throughout the examination period

Lab tests:

  • Sexually Transmitted Diseases – negative
  • Urinalysis – Within Normal Limits
  • Urine for pregnancy tests – negative
  • Complete Blood Count – Hemoglobin 8 g/dl, Hematocrit 32.9%

DIAGNOSIS

Diagnosis

  1. 1 Endometriosis ICD-10-CM N80.9

Differentials:

  1. Appendicitis ICD-10-CM K35.80
  2. Pelvic Inflammatory Infection ICD-10-CM N73.9

Plan:

  1. “Transvaginal Ultrasound” – to confirm the presence or absence of any structural abnormality, an ultrasound is required. This will be important in identifying the cysts that are formed due to endometriosis. Shafrir et al. (2018) noted that this is a vital step in treating endometriosis and should be a cheap and easily acceptable procedure.
  2. Medical Prescription (RX) – Percocet 5/325 1 tablet every 6 hours as needed to reduce the pain (35 pills, should not be refilled) since Nonsteroidal Anti-Inflammatory Drugs are no longer used to manage pain (Rolla, 2019).
  3. Referrals to Obstetrician/Gynecologist – diagnosis is carried out through “Laparoscopy.” Moreover, a biopsy is also necessary, although it will not be appropriate to initiate any hormonal contraceptive as AJ (the patient) desires. To ascertain that many endometrioses are removed, the patient needs to report back for conservative surgical operations. This process will also be made more accessible through laparoscopy (Agarwal et al., 2019). If she desires to get pregnant again, In Vitro Fertilization (IVF) will be necessary.
  4. Education:
  • Should not take hard drugs while taking narcotic pain prescriptions
  • Can reduce the sharp abdominal pains through exercise
  • Rolla (2019) says that the risks of endometriosis increase when one drinks a lot of alcohol. As such, one should not drink alcohol when trying to get pregnant.
  1. Precautions / Follow up
  • Ensure to keep doctor appointments regarding Obstetrician/Gynecologist referrals.
  • Conduct follow up visits after every 3 months
  • Consult your physician(s) if the pain worsens

ASSESSMENT

It is right to argue that this medical presentation suggests that the condition here is endometriosis. The patient (AJ) often experiences pain, worsening menstrual cramps, heavy menstrual flows (which are also irregular), and lower abdominal pains. These only happen as endometriosis gets worse. As a study by Chapron, Marcellin, Borghese, and Santulli (2019) suggests, having regular and persistent alcohol intake increases the likelihood of developing endometriosis.

References

Agarwal, S. K., Chapron, C., Giudice, L. C., Laufer, M. R., Leyland, N., Missmer, S. A., … & Taylor, H. S. (2019). Clinical diagnosis of endometriosis: a call to action. American journal of obstetrics and gynecology, 220(4), 354-e1.

Chapron, C., Marcellin, L., Borghese, B., & Santulli, P. (2019). Rethinking mechanisms, diagnosis, and management of endometriosis. Nature Reviews Endocrinology, 15(11), 666-682.

Rolla, E. (2019). Endometriosis: advances and controversies in classification, pathogenesis, diagnosis, and treatment. F1000Research, 8.

Shafrir, A. L., Farland, L. V., Shah, D. K., Harris, H. R., Kvaskoff, M., Zondervan, K., & Missmer, S. A. (2018). Risk for and consequences of endometriosis: a critical epidemiologic review. Best practice & research Clinical obstetrics & gynaecology, 51, 1-15.


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