Abnormal Uterine Bleeding: SOAP Notes, Essay Example

  • Hypothyroid

SUBJECTIVE

CC (Chief Complaint): “I am cold and tired all the time, and my skin has been very dry.”

 HPI (History of Present Illness/Issues)

  • Fatigue
  • Dry skin
  • Very sensitive to cold temperatures
  • Muscle aches
  • Irregular menstrual periods over the past six months
  • No visit to primary care physician since symptoms began
  • Prior to symptoms, health is generally normal for age

 PMH (Past Medical History)

 Reproductive

  • Normal menstrual periods until six months prior to visit
  • Using Norethindrone as birth control due to heightened sensitivity to estrogen

 Pregnancy/Birth

  • First child born healthy in 2001, second child in 2006

Age/Health Status

  • Age: 38
  • Health Status: normal/healthy; primary concerns are normal for the patient’s age group

Allergies

  • Allergic to cat hair
  • No known drug allergies

 Current Medications

  • Norethindrone (Micronor): 1x daily
  • Zyrtec OTC: 1x daily
  • Zantac 150: 1x daily as needed
  • Ibuprofen as needed

 Major childhood/adult illnesses, surgeries, hospitalizations, transfusions

  • Chicken Pox: age 9
  • Tonsillectomy: age 11
  • Emergency department for broken arm: age 14
  • Emergency department for minor car accident: age 18
  • Natural childbirth: 2001
  • Childbirth via cesarean section: 2006

Emotional Status

  • Routine physical examinations annually, including bloodwork, pap smear, other tests
  • Annual TB testing due to work requirement
  • Tetanus updated
  • Patient is responsive to health needs and contacts primary care provider as needed

FH (Family History)

  • Father (age 75): history of type 2 diabetes, hypertension, poor circulation, limited mobility (use of cane)
  • Mother: deceased in 2004, complications from head trauma in car accident; no known serious illnesses
  • Brother (age 42): no history of serious illness
  • Sister (age 34): 1 child (2012)
  • Family history of prostate cancer, diabetes, hypertension, COPD (grandfather)

SH (Social/Personal History)

  • Married for 15 years
  • Full time nurse at local hospital
  • BSN degree: 1998
  • MSN degree: 2008
  • Practicing Christian, does not exclude typical healthcare practices
  • Owns single-family home with husband
  • Exercises 3-4 times per week (spinning)
  • Normal stress levels
  • Financially stable, insurance coverage
  • No risks of violence at home, normal environmental and occupational risks

ROS (Review of Systems)

  • Height: 5’ 6”
  • Weight: 147 lbs.
  • BMI: 24.5
  • Overall positive wellbeing
  • BP: 127/75
  • Heart Rate: 86
  • Temperature: 98.0
  • Normal vital signs and reflexes

 Physical Exam

  • Skin is dry
  • Otherwise normal functioning
  • TSH Testing

Assessment

  • TSH: 4.6 mU/L

Assessment Notes

  • Prescribed Synthroid to stabilize T4 levels
  • Assess fatigue level in 3-6 weeks
  • Likelihood of improvement with continued medication and greater control
  • Abnormal Uterine Bleeding

SUBJECTIVE

CC (Chief Complaint): “I have had very heavy periods for the past four months and they make me very tired.”

 HPI (History of Present Illness/Issues)

  • Fatigue
  • Abnormal menstrual periods
  • Heavy bleeding
  • Length of periods keeps changing from month to month
  • Frequent change of tampons
  • Mood swings

 PMH (Past Medical History)

 Reproductive

  • Normal menstrual periods until four months prior to visit
  • No prescribed birth control

 Pregnancy/Birth

  • No children

Age/Health Status

  • Age: 32
  • Health Status: normal/healthy; primary concerns are normal for the patient’s age group


Allergies

  • No known drug allergies

 Current Medications

  • Ibuprofen as needed
  • Multivitamin 1x daily
  • Cranberry tablet 1x daily

 Major childhood/adult illnesses, surgeries, hospitalizations, transfusions

  • Chicken Pox: age 11
  • Emergency department for broken wrist: age 21

 Emotional Status

  • Routine physical examinations annually, including bloodwork, pap smear and other tests as needed
  • Tetanus updated
  • Patient is responsive to health needs and contacts primary care provider as needed

FH (Family History)

  • Father (age 62): history of hypertension
  • Mother: (age 60): history of type 2 diabetes, GERD
  • Sister (age 35): 2 children (2008 and 2011)
  • Family history of breast cancer (grandmother diagnosed in 2000; in remission)

SH (Social/Personal History)

  • Single, never married
  • Full time family law attorney
  • BA degree: 2004
  • JD: 2009
  • Practicing Catholic, does not exclude typical healthcare practices
  • Owns condo, lives alone
  • Exercises 5-6 per week (crossfit, running)
  • High stress levels
  • Financially stable, has good health insurance coverage
  • No risks of violence at home, normal environmental and occupational risks

ROS (Review of Systems)

  • Height: 5’ 4”
  • Weight: 130 lbs.
  • BMI: 22.3
  • Overall positive wellbeing in spite of stress
  • BP: 119/70
  • Heart Rate: 84
  • Temperature: 98.7
  • Normal vital signs and reflexes

 

Physical Exam

  • Skin is normal
  • Otherwise normal functioning/reflexes

Assessment

  • CBC
  • HCG to check for pregnancy
  • Pap smear

Assessment Notes

  • Abnormal bleeding
  • Abnormal CBC
  • Mild anemia
  • Evaluate pap test
  • No pregnancy
  • Evaluate patient in 4 weeks for further analysis and testing if heavy menstrual bleeding has not been alleviated
  • Preterm Labor

SUBJECTIVE

CC (Chief Complaint): “I am having contractions 12 minutes apart and I am 35 weeks pregnant.”

 HPI (History of Present Illness/Issues) 

  • Frequent contractions
  • Backache that has been dull off and on for two days
  • Spotting
  • Cramps

 PMH (Past Medical History)

 Reproductive

  • Normal menstrual periods until pregnancy
  • Used ethinyl estradiol and desogestrel (Ortho-Cept) until pregnancy was confirmed

Pregnancy/Birth

  • Currently pregnant with first child
  • No history of miscarriage

Age/Health Status

  • Age: 30
  • Health Status: normal/healthy; primary concerns are normal for the patient’s age group

Allergies

  • No known drug allergies
  • Allergic to peanuts

 Current Medications

  • Zantac 75: 1x/day as needed
  • Prenatal vitamin 1x daily
  • Iron 1x daily
  • Ibuprofen as needed

 Major childhood/adult illnesses, surgeries, hospitalizations, transfusions

  • Chicken Pox: age 8
  • Emergency department for broken ankle: age 13

Emotional Status

  • Routine physical examinations annually, including bloodwork, pap smear, other tests
  • Tetanus updated in 2012
  • Patient is responsive to health needs and contacts primary care provider as needed

FH (Family History)

  • Father (age 59): myocardial infarction (2010); angioplasty; hypertension and cholesterol are controlled by medication
  • Mother (age 60): no known serious illnesses; broken arm in car accident in 2011
  • Brother (age 28): 1 child (2010)
  • Sister (age 26): no known serious illnesses
  • Family history of hypertension, myocardial infarction, mild stroke (grandfather)

SH (Social/Personal History)

  • Married for 2 years
  • Full time social worker
  • BS degree: 2006
  • MSW degree: 2010
  • Practicing Christian, does not exclude typical healthcare practices
  • Rents townhome with husband
  • Exercises 5 times per week (walking, weight training prior to pregnancy)
  • Normal stress levels
  • Financially challenged due to low income, insurance coverage is adequate
  • No risks of violence at home, normal environmental and occupational risks

ROS (Review of Systems)

  • Height: 5’ 5”
  • Weight: 175 lbs.
  • BMI: 27.4
  • Overall positive wellbeing
  • BP: 148/85
  • Heart Rate: 92
  • Temperature: 99.0
  • Normal vital signs and reflexes

 Physical Exam

  • Pelvic exam conducted
  • Ultrasound to determine baby’s current status
  • Fetal and uterine monitoring
  • Laboratory tests as needed

Assessment

  • Hospitalization overnight for observation
  • Tocolytic to cease contractions
  • Bedrest upon discharge


Assessment Notes

  • Patient was admitted overnight for observation; if contractions cease with use of tocolytic, she will be discharged the following day
  • Bedrest to prevent additional contractions and other possible complications
  • Likelihood of improvement and full term delivery if stress levels are alleviated