Episodic/Focused SOAP Note
Episodic/Focused SOAP Note
L.R., 35, Female, Black
CC (chief complaint): “I need to have a pap test done.”
HPI: L.R. is a 35 year-old black female who presents to the clinic with the need for an annual Pap smear screening and breast mammogram. She missed the previous exam owing to the restrictions and risks of the pandemic. She complains of headache although she states it is not severe. The headache has been ongoing for three days. The headache has been leading to pounding effect and pressure around eyes and temples. Associated symptoms include nausea, vomiting, photophobia, and phonophobia. She experiences the headache after spending the whole day at work on the computer. The exacerbating and relieving factors include light in both eyes. She takes Naproxen to make it tolerable but not completely better. She rates the severity at 7/10 pain scale.
Current Medications: Naproxen 375 mg tablet BID.
Allergies: No known food or drug allergies.
PMHx: No major past illness or treatment. She has been having annual Pap smear screening in the past with no diagnosis.
Soc & Substance Hx: The patient is a librarian with 3 children. She is single and loves swimming over the weekend. She has been taking alcohol and tobacco. The intake has increased to the level of addiction. She denies abusing marijuana, cocaine, other hard drugs or prescription drugs. She lives with her sister and three children aged 10, 7, and 5 years.
Fam Hx: Her sister has cervical cancer and currently undergoing treatment. Her mother died of cervical cancer. Her dad is healthy and still alive. The children are healthy without any major health condition. She has no grandchildren.
Surgical Hx: No prior surgical procedures.
Mental Hx: No history of mental illness such as depression or anxiety. No history of self-harm or suicidal or homicidal ideation.
Violence Hx: No history of violence at home or work.
Reproductive Hx: Her LMP was 15th September. She had an abortion in the last year due to health complications. She is not using any contraceptives. She practices vaginal intercourse with multiple partners but since her abortion she has had no sexual intercourse.
GENERAL: No weight changes, body fever, chills, or fatigue.
HEENT: Eyes: No blindness or visual loss. No hearing problem, congestion, or sore throat.
SKIN: No lesions or itching.
CARDIOVASCULAR: No chest pressure, pain, or edema.
RESPIRATORY: No shortness of breath, sputum or cough.
GASTROINTESTINAL: No anorexia, diarrhea, or abdominal pain.
GENITOURINARY: No pregnancy or burning on urination. LMP 15/9/2021.
NEUROLOGICAL: No headache, ataxia, tingling in the extremities. No changes in bowel control.
MUSCULOSKELETAL: No muscle pain, stiffness, or join pain.
HEMATOLOGIC: No bleeding, or anemia.
LYMPHATICS: No history of splenectomy No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of anxiety or depression.
ENDOCRINOLOGIC: No history of heat intolerance, polyuria, or polydipsia.
REPRODUCTIVE: History of abortion due to health complications. She has foul smelling vaginal discharge. The discharge is watery, brown, and mixed with blood. She is currently not sexually active.
ALLERGIES: No history of rhinitis, eczema, hives, or asthma.
Physical exam: No physical examination carried out at this time of the gynecology visit.
Diagnostic results: The patient is coming for the gynecology visit. She missed an annual visit after she conceived. Various tests are needed to examine the risk of gynecology conditions. Breast mammogram is needed to establish the risk of breast cancer. A test for HPV is essential to examine infection in the reproductive system (Small et al., 2017). The patient should be tested for STI due to the behavior of multiple sex partners. A Pap smear test is vital to examine the risk of cervical cancer due to the hereditary nature of the condition (Small et al., 2017). Pelvic examination is vital to examine the risk of reproductive health in the female patient.
C53. 9 – Malignant neoplasm of cervix uteri, unspecified
A74. 9 Chlamydia billable/specific
O86. 11 Cervicitis billable/specific
D25.9 Uterine fibroid unspecified
N73. 9 Pelvic inflammatory disease billable/specific
Additional diagnostic tests and medical history is necessary to enhance the accuracy of the diagnosis. The patient requires additional tests to eliminate the risk of misdiagnosis (Ind, 2021). A referral to the laboratory is vital to examine the tissues for cancerous elements (Morgan et al., 2019). A blood test is necessary to eliminate the risk of cancer. The patient should take some painkillers to relieve the headache (Rastogi & Rome, 2021). Additional examination on the head should be done if the headache continues.
I agree with my preceptor about the case study.
One of the interventions of the condition is to encourage the patient to avoid multiple sex partners since they can increase the risk of reproductive health complications (Rastogi & Rome, 2021). Follow-up visits are needed to examine the severity of the condition and start of treatment.
I learned that a comprehensive examination of a patient’s history and chief complaint is vital to examine a patient.
In the future, I will strive to collaborate with other professionals to enhance the accuracy of the diagnosis. I will consider the cultural background of a patient to avoid sensitive conversations such as sex and reproductive parts with a female patient.
Lack or failure of access to the health facility for gynecology visits is one of the factors contributing to the deterioration of the condition (Rastogi & Rome, 2021).
Ind, T. (2021). Overview of fertility sparing treatments for cervical cancer. Best Practice & Research Clinical Obstetrics & Gynaecology.
Morgan, H. K., Winkel, A. F., Nguyen, A. T., Carson, S., Ogburn, T., & Woodland, M. B. (2019). Obstetrics and gynecology residents’ perspectives on wellness: findings from a national survey. Obstetrics & Gynecology, 133(3), 552-557.
Rastogi, R., & Rome, E. S. (2021). Adolescent Gynecology in the Office Setting. Pediatrics in Review, 42(8), 427-438.
Small Jr, W., Bacon, M. A., Bajaj, A., Chuang, L. T., Fisher, B. J., Harkenrider, M. M., … & Gaffney, D. K. (2017). Cervical cancer: a global health crisis. Cancer, 123(13), 2404-2412.