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