Midwifery and Women's Health Soap Note

Comprehensive Women’s Health History and Physical Template

Encounter date: 

Patient Initials: M.S Gender: F Age: 35 Race/Ethnicity: Black

Reason for Seeking Health Care: ‘I have been experiencing very painful periods and heaving bleed since last week’

History of Present Illness (HPI): 

The patient is a 35-year-old lady that presented to the clinic with the complaint of severe pelvic discomfort and excessive bleeding coinciding with the onset of her menstrual cycles last week. The patient reports that she has experienced the same condition for a duration of 3 months during her monthly periods, and this is not the first occurrence. She reports that her pain level is 8 out of 10, describing it as a stabbing sensation. The pain is more strong during the initial days of her menstrual cycle. During the first consultation, the patient also stated that they did not have any bleeding or nausea.

Allergies (Drug/Food/Latex/Environmental/Herbal) : Non was reported by the patient.

Current Perception of Health : Her current perception of health is absence of disease and so she currently feels unhealthy and sick

Current Medications (including over the counter): patient uses Ibuprofen 600mg for relieving pain during her menses.

Menstrual History

Age at Menarche: 12 years old.

Last menstrual period: 27/10/2021

Menstrual Pattern: Regular

Cycle Length: 28 days.

Duration of Flow: Four (4) days.

Amount of Flow : Heavy.

Bleeding Pattern: Continuous.

Break through Bleeding: Occasional but not regularly.

Gynecologic History

History of breast disease, breast feeding, use of self-breast exam, last mammogram (if applicable): Does not apply to the patient

Previous GYN surgery (may include that in surgical history): patient has no history

History of infertility: Patient reports no history of infertility. 

History of diethylstilbestrol (DES) use by patient’s mother: patient does not report any history with negative use of DES by her mother. 

Last pap smear, history of abnormal pap: The patient did her last pap smear about 1 year ago. She also did her HPV test with no abnormal results. 

Pre-menopause/menopause

Vasomotor symptoms: negative for any pre-menopause vasomotor symptoms such as hot flushes.

Hormone Replacement Therapy: patient reports negative for history of hormonal replacement therapy.

Sexual and Contraceptive History

Current method of contraception: The patient is not currently on any contraception. 

Sexually active: patient was last sexually active 4 weeks ago. 

Number of sexual partners: She is engaged to her boyfriend who is also the only sexual partner. 

New partners in the 3-6 months: Non

Condom use: Occassionally use condoms when not in safe days.

History of sexual abuse: Non

History of sexually transmitted infections (STIs): Once was diagnosed with chlamydia

Obstetric History (including complications): No history as she has no children

Past Medical History (PMH):  Patient has history of asthma

Major/Chronic Illnesses: Asthma

Trauma/Injury: None.

Hospitalizations: None.

Past Surgical History: Patient reports negative for surgical history

Family Medical History: Mother is alive with diabetes, she has two sister all of whom are obese, and father is deceased of natural causes. 

Social History

Living condition: patient lives with her boyfriend in a spacious two bedroom house in the city. 

Marital status:  Patient is engaged not married.

Education: she is an under graduate with bachelors of education.

Employment:  currently employed and working as a tutor in the community high school

Occupation: Teacher.

Social supports:  patient has a strong support system comprising of mother and her boyfriend.

Habits (smoking, alcohol use and illicit drugs use):  Patient reports smoking in a social gathering, also drinks alcohol but during social events, she is not a heavy drinker and does not use drugs. 

Health Maintenance 

Age-appropriate health promotion/maintenance and screening history: patient has been provided with health education especially when it comes to persona hygiene, communicable disease and the importance of regular health check ups. 

Immunization history:  Patient is up to date with all immunization requirements including covid 19. 

Review of Systems (ROS)

General:  Patient denies Weight change, fever, chills, or fatigue. 

Cardiovascular: Patient denies chest pain.

Respiratory: Patient denies Rales, SOB, coughing or production of sputum.

HEENT: Patient denies loss of vision or hearing. Refutes sore throat.

Gastrointestinal: Patient denies bowel abnormalities, nausea, vomiting, constipation, or

Diarrhea.

Genitourinary: Patient denies burning sensation during urination.

Skin: There is no change in the patient’s skin such a dryness, itching, rashes, and discoloration.

Breast: Patient denies masses. Negative for nipple discharge. They are firm and symmetrical.

Musculoskeletal: Negative for abnormalities. Negative for pains at joints or in muscles.

Neuro: Positive for Headaches, LOC, or dizziness absent. Negative for tremors while moving.

Hema/Lymph/Endo: There is evidence that the patient needs assessment since the lymph nodes they are palpable, however, they are not swollen. 

Psych: Patient denies being depressed. Negative for mental conditions.

Physical Examination

HEENT

General: AC is well nourished, well appearing, and well groomed.

Normocephalic. The patient’s hair is intact. No lesions on the head.

Eyes: PERRLA. Have no abnormalities.

Ear: No hearing impairment. Ears are intact.

Nose: mucosa is moist and of color pink.

Mouth: No bleeding or ulcerations.

Thyroid: No abnormalities

Cardiovascular

Patient has a regular rhythm, with no murmurs or edema

Respiratory

No wheezing, coughing, rales, or rhonchi. Clear lungs upon auscultation

Gastrointestinal

Non-tender, soft abdomen. Bowel sounds presents in all 4 quadrants.

Genitourinary

The patient’s external genitalia are normal. No irritation noted on the urethra. No vaginal

Discharge. The mucosa is healthy and pink. No masses on the uterus.

Skin

Intact

Extremities

No abnormalities observed.

Lymph: WNL

Vitals: 

Height: 5’4” Weight: 124 lbs. BMI: 34.7 kg per m2    Temp: 98.9 °F BP: 119/64 mmHg Resp: 18 per min Pulse: 85 bpm

HIRE ONLINE SOAP NOTE WRITERS

Significant Data/Contributing Dx/Labs/Misc Lab Tests Recommend Urinary tests.  Manual breast examination awaiting results.  Transvaginal Ultrasound; Negative. No fibroids, ovaries are normal

Differential Diagnoses 

1. Dysmenorrhea (N94.6) - This is the main diagnosis for the patient. Dysmenorrhea is the medical term used to describe period discomfort or menstrual cramps, as stated by Horiba et al. (2017). There are two types of dysmenorrhea: primary and secondary. Menstrual pains that occur repeatedly and are not attributed to other diseases are typically classified as this syndrome. Typically, pain arises a day or two prior to menstruation or at the onset of bleeding. The patient may have varying degrees of discomfort, ranging from mild to intense, in the lower abdomen, back, or thighs. The duration of pain can range from 12 to 72 hours, and the patient may also encounter symptoms such as nausea, vomiting, fatigue, and even diarrhea (Horiba et al., 2017). Dysmenorrhea may diminish in intensity with age and potentially cease altogether following childbirth. Secondary dysmenorrhea is characterized by painful menstrual cycles caused by a specific issue or infection in the patient's reproductive systems. Secondary dysmenorrhea pain often initiates earlier in the menstrual cycle and endures for a longer duration compared to regular menstrual cramps. Nausea, vomiting, fatigue, or diarrhea are infrequent adverse reactions.
2. The major diagnosis of the patient is dysmenorrhea, based on the assessment which reveals pathological indications connected with the patient's menstrual cycle. This symptom is also associated with the occurrence of stomach cramping and severe pain experienced by the patient during their menstrual cycles. Occasionally, this can result in additional symptoms including diarrhea, nausea, vomiting, and headache (Horiba et al., 2017). I hypothesized that the patient is suffering from dysmenorrhea, as the discomfort progressively intensified with each menstrual cycle and persisted till the end of the period. Regarding this matter, the patient is 35 years of age and has been experiencing painful menstrual cycles for the past 3 months. This confirms the correct diagnosis and will aid in identifying the root cause. 
3. Uterine Fibroids (D25.9) - This was the second potential diagnosis. Excessive menstrual bleeding is typically indicative of an underlying medical condition. Menstrual periods that exceed a duration of seven days, Experiencing discomfort or pressure in the pelvic area Frequent urination, Experiencing difficulty in voiding the bladder, Symptoms of backache or leg soreness, as well as constipation
4. Fibroids can impact women in their reproductive years, with a higher susceptibility observed among black women compared to women of different racial backgrounds (Thao et al., 2021). In addition, black women have a higher likelihood of developing fibroids at an earlier age. They are also more prone to have a greater number or larger fibroids, along with more severe symptoms. While uterine fibroids are generally not dangerous, they can lead to pain and complications such as anemia, which is characterized by a decrease in red blood cells and can cause fatigue due to excessive blood loss. In rare instances, blood loss may require a transfusion. The patient's condition can be described as uterine tumors, which typically result in irregular uterine bleeding, pelvic pain, and complications during pregnancy. The condition can be assessed by doing MRI, such as Ultrasonography or pelvic examination (Thao et al., 2021). Considering the patient's medical background, it seems plausible that she is experiencing this ailment. However, the ultrasound results have ruled out this possibility. 
5. Pelvic Inflammatory disease (N73.9) - This syndrome arises when the female reproductive organs become infected. The reproductive organs are the anatomical structures responsible for the process of conception and childbirth. Pelvic inflammatory disease (PID) affects the uterus, ovaries, and fallopian tubes, which are reproductive organs. If you have PID, you may encounter lower abdominal pain in your stomach region. In addition, you may encounter atypical discharge (leakage) in the vicinity of your vaginal region (Higuera, 2021). Although the majority of PID infections are transmitted sexually, 15 percent of these infections are not acquired through sexual contact with an infected partner. Bacteria can enter the reproductive system through sexual intercourse, where they have the potential to harm the organs (Higuera, 2021). Pelvic inflammatory disease (PID) has the capacity to adversely affect multiple components of the patient's reproductive system, such as the uterus, ovaries, and fallopian tubes. Pelvic inflammatory disease (PID) can cause discomfort and hinder fertility if not treated promptly. Pelvic inflammatory disease (PID) can also lead to the formation of a tubovarian abscess (TOA), which is a localized infection within the pelvis. If not promptly treated, TOA can give rise to significant health complications (Higuera, 2021). The diagnosis could potentially apply to the patient. However, it was excluded as a possibility as she had no previous medical record of sexually transmitted infections (STIs) or pelvic inflammatory disease (PID). Typically, pelvic inflammatory disease (PID) causes discomfort on both sides of the pelvis. However, the patient in this case reported suffering pain on only one side. 

Primary Diagnoses: Dysmenorrhea.

Pharmacologic

While awaiting the test results to confirm the presence of any other infections, the patient will be advised to continue taking Ibuprofen 600mg to alleviate pain during episodes of cramping or bleeding. The painkiller is classified as a non-steroidal anti-inflammatory medication (NSAID). If the patient does not experience any sensation, she may consider using alternative analgesics.

Therapeutic

• Rest when needed. 
• Place a heating pad or hot water bottle on your lower back or abdomen. 
• Avoid foods that contain caffeine. 
• Massage your lower back and abdomen
• Avoid smoking and drinking alcohol. 

Education

• Conduct physicals to ensure that the body is not strained. 
• Mark dates and time when cramps begin. 

• To reduce the chance of developing fibroids, it is crucial to ensure that the patient adopts a healthy lifestyle, which includes keeping a healthy weight and consuming a diet rich in fruits and vegetables.

Follow up

After two weeks.

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Patient Name: (Initials)_____M.S_________________________        Age __35________

Date: _______________

RX : Ibuprofen 600mg for pain when the cramping or bleeding starts

SIG: 

Dispense:  ___________                                                     Refill: _________________

       No Substitution 

Signature: ____________________________________________________________

Signature (with appropriate credentials): __________________________________________

References (must use current evidence-based guidelines used to guide the care [Mandatory])

References

Higuera, V. (2021). Pelvic inflammatory disease (PID). Healthline. https://www.healthline.com/health/pelvic-inflammatory-disease-pid#outlook

Horiba, Y., Yoshino, T., & Watanabe, K. (2017). Effectiveness of Japanese Kampo treatment in dysmenorrhea: Single-center observational study. Traditional & Kampo Medicine, 5(1), 51-55. https://doi.org/10.1002/tkm2.1088

Thao, V., Moriarty, J., Stewart, E., & Borah, B. (2021). PIH9 cost-effectiveness of Myomectomy VS. Hysterectomy in women with uterine Fibriods. Value in Health, 24, S101. https://doi.org/10.1016/j.jval.2021.04.527