Posted: December 30th, 2021

Gynecology Episodic/Focused SOAP Note

Episodic/Focused SOAP Note

Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date

Episodic/Focused SOAP Note
Patient Information:
LB, 35, Female, African-American
S.
CC (chief complaint): Present for annual gynecology visit, breast mammogram,
HPI: LB is a 35-year old African-American female who presents for annual gynecology visit, breast mammogram. She missed the previous exam owing to the restrictions and risks of the pandemic.
Current Medications: Aspirin 81mg daily, allergy meds as needed, Tums as needed with her meals by mouth, Melatonin 3mg as needed by mouth at night
Allergies: Allergic to changes in weather. No drug allergy.
PMHx: No history of illness, admission in hospital, or surgeries.

Soc & Substance Hx: No alcohol or tobacco use. No family member with breast cancer or reproductive health illness.
Fam Hx: No history of illness in the family. Lives alone but has a boyfriend.
Surgical Hx: No past surgical procedures.
Mental Hx: No history of diagnosis with mental illness.
Violence Hx: No history of violence.
Reproductive Hx: The patient has no children. She is preparing to have children in the next year. History of UTI without signs reported or assessed. No pregnancy. No birth controls used.
ROS:
GENERAL: No unintentional weight loss or gain, fever, or fatigue.
HEENT: No visual loss, double vision, hearing loss, congestion, or sore throat.
SKIN: No itching, rashes or lesions.
CARDIOVASCULAR: No chest pain, pressure, or discomfort.
RESPIRATORY: No coughing or shortness of breath.
GASTROINTESTINAL: No vomiting, nausea, or diarrhea.
GENITOURINARY: No changes in bladder control. History of UTI.
NEUROLOGICAL: No dizziness, headache or irregular bladder control.
MUSCULOSKELETAL: No pain in the muscles, joint, or back.
HEMATOLOGIC: No bleeding or anemia.
LYMPHATICS: No history of splenectomy.
PSYCHIATRIC: No history of mental illness.
ENDOCRINOLOGIC: No head or cold intolerance.
REPRODUCTIVE: No pregnancy, not sexually active, preparing to have children. No birth controls pills used.
ALLERGIES: No history of hives or rhinitis.
O.
Physical exam: No physical exam carried out.
Diagnostic results: The patient is coming for the gynecology visit after missing last years’ annual examination. A battery of tests is needed including a breast mammogram to look for signs of breast cancer (Bowden et al., 2021). She also needs Human papillomavirus (HPV) test or STI blood test to check for sexually transmitted infection. A Pap test is necessary to check for cervical cancer (Bowden et al., 2021). The pelvic exam will be essential to assess the gynecological health of the woman (Bowden et al., 2021).
A.
Differential Diagnoses
N87. 1: Moderate cervical dysplasia
Cervical dysplasia involves the abnormal growth of cells in the cervix. The cells are not malignant but they can be cancerous. It can take almost 10 years for a full cancer diagnosis (Dushkin et al., 2021).
N84.1 Cervical polyp
Cervical polyps are growth occurring in the cervical canal. The growth is reddish and taking the shape of a bulb. The condition occurs due to infection or high levels of estrogen (Pegu et al., 2020).
C85. 91 Cervical lymphoma unspecified
Cervical lymphoma is a rare tumor with an occurrence of 1 percent among cervical malignancies. One of the major symptoms is abnormal bleeding. A cervical smear can be used to detect the tumor (Pegu et al., 2020).
D25.9 Leiomyoma of the uterus, unspecified
The condition comprises uterine fibroids comprising of muscles and connective tissue. The condition is not cancerous but annual monitoring is necessary. It is the most common pelvic tumor in women (Sun et al., 2019).
P.
Effective planning of the treatment plan should be done to ensure the health of the patient. For instance, referrals are necessary to ensure further tests are carried out. The patient is coming for the annual examination but further blood and tissue tests are needed to ascertain the health condition. The interventions are necessary to determine the condition of the vagina, cervix, and entire reproductive system (Carty et al., 2020).
It will be important to educate the patient about the health risks of sexual intercourse. The woman should learn the need to practice safe sex with the boyfriend. She needs to avoid sexual intercourse with multiple partners since the behavior can increase the risk of HPV. It is vital to inform the patient to ask the partner to be tested for sexually transmitted infection (Carty et al., 2020). The tests are necessary to take precautions or begin early treatment. The precaution is vital as the patient prepares to have children.
The patient should visit the gynecologist within three months and later after one year. The purpose is to examine the condition of the reproductive system, provide treatment, and assessment (Dushkin et al., 2021). It is vital to educate the patient to always visit the healthcare facility annually for a checkup. When she conceives it will be vital to visit a mother and child clinic for assessment and prenatal care.
It is vital to emphasize the need to get vaccinated. I will provide vitamins to the patient to boost immunity to maintain good health despite the risk of viral infection. Currently, there is no help in preparation for the pregnancy. The patient needs to maintain good health.
I learned that patients are likely to miss planned visits during the pandemic. The missed visits can expose the health of patients. I would encourage the patient to come with the partner after three months and annually. The tests are vital to secure their health, diagnose conditions early, and provide early interventions.
During the delivery of care, it will be effective to observe ethical guidelines. Ethical care should comprise providing respectful care to the woman irrespective of her age and ethical background (Dushkin et al., 2021). It will be important to provide professional practice to avoid medical errors or patient harm.

References
Bowden, S. J., Lathouras, K., & Kyrgiou, M. (2021). Can DNA methylation tests improve the accuracy of cervical screening?. BJOG: An International Journal of Obstetrics & Gynaecology, 128(3), 515-515.
Carty, M., O’Riordan, N., Ivers, M., & Higgins, M. F. (2020). Patient perspectives of bedside teaching in an obstetrics, Gynaecology and neonatology hospital. BMC medical education, 20(1), 1-9.
Dushkin, A. D., Afanasiev, M. S., Zatevalov, A. M., Aleshkin, V. A., Mironov, A. Y., Afanasiev, S. S., … & Karaulov, A. V. (2021). Digital analysis and quantitative assessment of the cervical surface with dysplasia. Klinicheskaia Laboratornaia Diagnostika, 66(7), 417-421.
Pegu, B., Srinivas, B. H., Saranya, T. S., Murugesan, R., Thippeswamy, S. P., & Gaur, B. P. S. (2020). Cervical polyp: evaluating the need of routine surgical intervention and its correlation with cervical smear cytology and endometrial pathology: a retrospective study. Obstetrics & Gynecology Science, 63(6), 735-742.
Sun, S., Bonaffini, P. A., Nougaret, S., Fournier, L., Dohan, A., Chong, J., … & Reinhold, C. (2019). How to differentiate uterine leiomyosarcoma from leiomyoma with imaging. Diagnostic and interventional imaging, 100(10), 619-634.

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