Create 25 women's Health Soap notes

User Generated

Zvyyvfpragybvfr

Mathematics

University of Melbourne

Description

Create 25 women's Health Soap notes. Avoid repeating diagnosis. This needs to be from an FNP new grad perspective. Include a variety of preventive visits,acute, chronic, and wellness disorders pertaining only to this population.

Documentation Requirements

Must Include

  • Patient Demographics Section:
  • Age
  • Race
  • Gender
  •  Clinical Information Section:
  • Time with Patient
    o Reason for visit
    o Chief Complaint
    o Social Problems Addressed
  •  Medications Section:
    o # OTC Medications taken regularly
    o # Prescriptions currently prescribed
    o # New/Refilled Prescriptions This Visit
  •  ICD 10 Codes Category:
    o Include for each diagnosis addressed at the visit
  •  CPT Billing Codes Category:
    o Include Evaluation and management code
    o Provider procedure codes (pap smear, destruction of lesion, sutures, etc.)
  •  Other Questions About This Case Category:
  • o Age Range
  • o Patient type
    o HPI
    o Patients Primary Language
    o Did you chart on the patient record?
    o Discussed Management with the Preceptoro Handled Visit Independently
    o Preceptor Present During Visit

2 mins ago

account_balance University of Melbourne

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Explanation & Answer

Attached.

Running head: SOAP NOTES

1

Soap Notes for Women’s Problems
Name
Institutional Affiliation

SOAP NOTES

2
Soap Notes for Women’s Problems
Genital Herpes

Patient Demographics






Name:
Mary Clark
Age:
42
Race:
Caucasian White
Gender:
Female
Primary language: English

Clinical Information
Chief Complaint:
The patient presented to the centre on 15th December, 2018 with lower abdominal pains.
History of present illness and analysis of symptoms
Patient reports pains in the lower abdomen, prolonged menstrual bleeding
Social problems
The has two children 10 and 5, divorced and lives with her children and her sister in an
apartment.; alleged rape three months ago on her way from work.
Assesment:
VS: HR 66 BP 80/89. Ht 5’5, Wt 123 lb. BMI 18.5



Pt is alert and oriented
Client is interactive

Diagnostics:



Blood test shows presence of HSV-1
Urine test shows urine color is yellow, appearance hazy, blood spotted

PLAN:
Therapeutics:
1. Continue current medication
• Acetaminophen for lower abdominal pain
• Naproxen Sodium to reduce menstrual loss

SOAP NOTES
2. Start




3

Midodrine for low blood pressure
Acyclovir, 400 mg twice daily for HSV-1
Acyclovir topical ointment to treat genital sores

The plan at this time is to let the patient use the medication for two weeks and return for
evaluation. We shall recommend a pap smear test if symptoms persist.
ICD 10 Codes Category
ICD 10 Codes
R 10.33
626.2
R03.1
4687

Description
Acute lower abdominal pain
Prolonged menstrual bleeding
Low blood pressure
Recommended test for
antibodies

Z04.4

Problem started after alleged
rape

Education:
1. Discuss with the patient on the need to monitor daily blood pressure.
2. Advice patient to keep her genital area clean and avoid sexual contact.
3. Patient needs to take plenty of fluids and fruits to increase her blood level.
Consultation/Collaboration:
The nurse handled visit independently, ordered client to return to the clinic after two weeks for
checkup.
Endometriosis

Patient Demographics






Name:
Lucile Grace
Age:
26
Race:
African American
Gender:
Female
Primary language: English

Clinical Information

SOAP NOTES

4

Chief Complaint:
Patient presented to the center on 1st November, 2018 with severe head ache, lower abdominal
and back pains.
History of present illness and analysis of symptoms
Client reports that the pains in her lower back started a month ago, followed by pains in the
lower abdomen. She has pains during defecation, painful menstruation
Social problems
Client has no child but lives with her boyfriend. She does not smoke but takes alcohol two times
a week. She fell on her way from school one year ago.
Assesment:
VS: HR 63 BP 120/90. Ht 5’4, Wt 85 lb. BMI 20.5


Pt is interactive and alert

Diagnostics:



Pelvic examination shows no abnormalities in the abdomen
MRI results show presence of abdominal cysts

PLAN:
Therapeutics:
1. No current medication
2. Physician recommends laporascopy
3. Start
• Metamucil to ease pelvic movement
• Ibuprofen to relieve headache , back and abdominal pain
• Tranexamic acid to reduce menstrual loss.
The plan at this time is to send the patient for laporascopy for the removal of the abdominal
cysts.
ICD 10 Codes Category
ICD 10 Codes
R 10.33
R51
R15.0
626.2

Description
Acute lower abdominal pain
Severe headache
Painful defecation
Prolonged menstrual bleeding

SOAP NOTES

5

W19.XXXA

Unspecified fall initial encounter

V64.41

Patient undergoes laparoscopy

Education:
1. Patient needs to take a lot of rest after procedure and replace bandage after two days.
2. Take plenty of fluids, fruits and vegetables.
3. Avoid strenuous exercises within 48 hours of procedure.
Consultation/Collaboration:
The nurse handled visit in collaboration with the preceptor and ordered client to return for
assessment after three weeks.
Receptor present: Calvin Jones
Cervical Dysplasia
Patient Demographics






Name:
Monique Graham
Age:
16
Race:
African American
Gender:
Female
Primary language: English

Clinical Information
Chief Complaint:
Patient presented to the center on 20th January, 2019 with prolonged acute pain in the lower
abdomen
History of present illness and analysis of symptoms
Client reports pain in the lower abdomen for the last three months.
Social problems
Client has no child but is sexually active.
Assesment:
VS: HR 70 BP 116/90. Ht 4’3, Wt 75 lb. BMI 22.5

SOAP NOTES


6

Pt has anxiety but is interactive

Diagnostics:



Pelvic examination shows no abnormalities in the abdomen
Pap smear test detected granular cells

PLAN:
Therapeutics:
1. No current medication
2. Physician recommends ibuprofen to ease abdominal pain and laser treatment to remove
abnormal cells
The plan at this time is to go for colposcopy to determine the extent of the granular cells. The
patient will undergo laser treatment to remove the cells.
ICD 10 Codes Category
ICD 10 Codes
R 10.33
57454

Description
Acute lower abdominal pain
Patient to undergo colposcopy

Education:


Patient needs to maintain hygiene around the genitals.

Consultation/Collaboration:
The nurse handled visit in collaboration with the preceptor and ordered client to return for
assessment after one month.
Receptor present: Calvin Jones
Uterine fibroids
Patient Demographics






Name:
Isaak Joseph
Age:
36
Race:
Asian
Gender:
Female
Primary language: English

Clinical Information

SOAP NOTES

7

Chief Complaint:
Patient presented to the center on 16th December, 2018 with frequent urination and heavy
menstrual bleeding.
History of present illness and analysis of symptoms
Client reports pain in the lower abdomen, frequent urination, constipation and heavy menstrual
bleeding that have persisted for two weeks.
Social problems
Client has one child aged 5 years. She is married and lives with her husband in a rented house.
She works as a secretary at a school.
Assesment:
VS: HR 80 BP 115/90. Ht 5’3, Wt 175 lb. BMI 19.5


Pt is active and interactive.

Diagnostics:


Hysteroscopy results show presence of uterine fibroids

PLAN:
Therapeutics:
1. Continue with Acetaminophen for pain relief in the lower abdomen.
2. Start using progestin-releasing intrauterine device and Tranexamic acid to reduce
menstrual bleeding, darifenacin to control bladder movement
The plan at this time is for the patient to use a progesterone IUD and tranexamic acid to reduce
menstrual bleeding. They will then undergo cryomyolysis to freeze the cells.
ICD 10 Codes Category
ICD 10 Codes
R 10.33
626.2
R35.0
K59.00
68.12
Education:

Description
Acute lower abdominal pain
Prolonged menstrual bleeding
Frequency urinating
For constipation
Recommended hysteroscopy

SOAP NOTES




8

Patient needs to maintain hygiene around the genitalia
Pelvic exercises to regain normal bladder movement
Take plenty of fluids

Consultation/Collaboration:
The nurse handled v...


Anonymous
Really helpful material, saved me a great deal of time.

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