Family: Week 8 SOAP Notes
|Name: KJ||Date: 27th December 2017||Time: 14hours|
|Age: 20 years||Sex: Female|
“I have come because I am afraid I am pregnant and I need to see the doctor.”
The patient states that she was well until she noticed that she had missed her periods. She says that her LMP was six weeks ago and she says she does not recall the exact date. She is G1 P0. She says that she has not had a pregnancy test because she is afraid of the results because her culture does not allow sexual relations before marriage. She reports nausea, weird cravings, mild breast tenderness, and denies any vaginal bleeding. She, however, reports vaginal discharge that is whitish and thick with no odor and requires her to wear pads. She said it had started four weeks before and she has some pain during intercourse. She denies any itching or burning.
None apart from herbs she is using to alleviate nausea.
She develops a rash when she eats red meat.
Medication Intolerances: None.
Chronic Illnesses/Major traumas: She reports that she has had good health and has never had any significant injuries or diseases. She says she had only common childhood sicknesses such as URI and otitis media.
Hospitalizations/Surgeries: KJ has never been hospitalized or had surgery.
The mother and father are obese and have diabetes. All her siblings are also obese. There is no history of other chronic conditions in the family. She also says she has not had any recent contact with sick persons.
She dropped high school and currently works as a cook in a family restaurant in the city. She lives with her parents and siblings in a three-bedroom apartment. They are staunch Catholics. She has a boyfriend, of whom the parents are not aware. She does not drink or smoke cigarettes as their cultural beliefs are against it. She states that she drinks clean water but often consumes junk foods. All her immunizations are as per schedule. She always wears a seat belt when in a car.
She reports increased appetite and weight gain of around 4 pounds in the last two months. She has no fatigue, malaise, or fever.
She has not had any SOB, palpitations, limb swelling, or chest pains.
She has no bruises, rashes, moles, or skin discoloration.
She denies any coughing, DIB, coughing up blood, or history of any lung illness.
She has no blurring vision, eye discharge, or any eye pains.
She has nausea and an increased appetite. She denies any diarrhea or constipation. She has no bowel changes, abdominal cramping, fissures, or hemorrhoids.
She denies any tinnitus, ear discharge, or loss of hearing.
She does not report any urinary color changes, urgency, incomplete voiding, dribbling, or frequency. She is not on any contraception apart from condoms, which she uses inconsistently. She has never had a mammogram or pap smear. She states that she has thick vaginal discharge that is yellow. She has never been pregnant.
She has no coryza, nose discharge, or any bleeding. She also denies any missing tooth or dental diseases. She has no odynophagia or dysphagia.
She reports some slight back aches but denies any joint inflammation, stiffness, pain or effusion.
She performs a self-breast exam and denies noticing any breast lumps or discharge.
She denies any paralysis, fainting, seizures, tremors, and pins and needle feeling.
She is seronegative, has never been transfused, and denies adenopathy, increased thirst, heat and cold intolerance.
She denies any delusions, hallucinations, suicidal thoughts, depressive episodes, or sleeping difficulties.
|Weight 170 pounds BMI 27.4||Temp 36.7C||BP 117/78mmgh|
|Height 5’6’||Pulse 88||Resp 14|
Overweight Hispanic lady in a fair condition, who does not seem to be in any acute distress. The woman is calm and answers questions correctly, although she looks a bit worried.
Her skin is well hydrated, soft, and supple. It is without any lesions or rashes.
Head: Her head has no obvious injuries and proper hair distribution. Eyes: the pupils are PERRLA; no conjunctiva infection; the sclera is anicteric. Ears: both canals are patent, and the eardrums are not inflamed. Nose: the mucosa is pink, and the septum is central. Neck has full ROM without adenopathy. The thyroid gland is normal in size. The oral mucosa has no ulcers; the teeth are in a good condition. Throat: The pharynx and tonsils are not enlarged, and there are no exudates.
Heart with regular rhythm and rate and no gallop or murmur. No tachycardia, edema, and the peripheral pulse is normal. The cap reflow is < 2seconds.
She has a normal chest wall with no retractions. Her breathing is not labored, and the lungs are clear to auscultation both anteriorly and posteriorly.
Her abdomen is obese and round. It is soft, and the fundus is not palpable. There are no masses, and the liver span is 7cm. The spleen is not palpable. The BS is present in all abdominal quadrants.
The breasts are tender to touch. There is no thickening, masses, or discharge present. She does not have any dimpling or skin discoloration.
The external genitalia are normal without lesions. Speculum exam reveals dark, nulliparous and pink cervix. There is a large amount of whitish discharge that is thick and odorless. There is cervical motion tenderness. The uterus is anteverted, and there are no adnexal masses on bimanual palpation.
All muscle groups have normal tone, strength, and bulk of full ROM. The spine is also normal, and the joints move adequately. Tendon reflexes are normal.
The patient has a clear and audible speech. All the cranial nerves are intact, and the balance is normal.
The patient has good judgment, she is alert and oriented. She avoids direct eye to eye contact and looks shy, but her speech is clear. She responds to questions well.
Urinalysis – normal
Wet prep positive for WBC but negative for clue cells, hyphae, or trichomonas.
KOH negative whiff test.
Blood culture and sensitivity
Blood type and Rh
Gonorrhea and Chlamydia screen (Kennedy-Malone, Fletcher, & Martin-Plank, 2014).
| Differential Diagnoses
· 1- Pregnancy Z34.00
· 2- Ectopic pregnancy O00.9
· 3- Molar pregnancy O01.9
· 4- Pelvic inflammatory disease N73.9
· Pregnancy- the patient has signs and symptoms of a pregnant person. She missed her period, has tender breasts, food cravings, morning sickness, and her pregnancy test was positive (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013).
· Further testing
Prenatal multivitamins including folic acid supplementation
Azithromycin 1gm orally and ceftriaxone 250 mg IM once to help fight the suspected PID infection (Kennedy-Malone et al., 2014).
Ondansetron 4 mg orally daily to prevent nausea.
She should avoid sexual intimacy until she completes the antibiotic treatment.
She should avoid douching or any irritants to the vagina.
She should take the drugs strictly as provided to help eliminate the infection (Kennedy-Malone et al., 2014).
She should call the doctor if she develops a fever, severe leg swelling, bleeding or rupture of membranes.
· Non-medication treatment
She should do exercises to help her reduce her weight, for instance walking for at least thirty minutes daily (Buttaro et al., 2013).
She should also avoid junk food and any processed food that may lead to weight gain. Instead, she should eat a plenty of vegetables and fruits.
She should avoid any contact with secondary smoke.
She should schedule prenatal care visits to the physician every four weeks until week 28 and then every two weeks till week 36, then weekly till delivery (Buttaro et al., 2013).
You may find this article Nursing SOAP Note Writing Service useful.