6551 WK 3 SOAP

Gynecologic Health

Select a patient that you examined as a nurse practitioner student during the last three weeks of clinical on OB/GYN Issue. With this patient in mind, address the following in a SOAP Note 1 OR 2 PAGES :

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Subjective: What details did the patient provide regarding her personal and medical history?

Objective: What observations did you make during the physical assessment?

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters for this patient , as well as a rationale for this treatment and management plan.

Very Important:  Reflection notes: What would you do differently in a similar patient evaluation?

Sample Solution

SOAP Note for Gynecologic Health Assessment

Subjective: The patient, a 30-year-old female, presented with complaints of abnormal vaginal bleeding and lower abdominal pain. She reported that her menstrual cycles had become irregular over the past few months, with heavier bleeding than usual. The patient denied any history of sexually transmitted infections, pelvic inflammatory disease, or previous surgeries. She mentioned that she is sexually active and uses condoms for contraception. Additionally, the patient stated that she had been experiencing dyspareunia (pain during sexual intercourse) and occasional pelvic discomfort.

Objective: Upon physical assessment, the patient appeared in no acute distress. Vital signs were within normal limits. Abdominal examination revealed mild tenderness in the lower quadrants, with no palpable masses or organomegaly. Speculum examination of the vagina showed no signs of inflammation, discharge, or lesions. The cervix appeared normal, with no evident abnormalities. Bimanual pelvic examination elicited mild tenderness on palpation of the adnexal areas. No masses were detected during the examination.

Assessment: Based on the patient’s history and physical findings, the following differential diagnoses were considered:

1. Uterine fibroids: Given the patient’s complaint of heavy and irregular bleeding, uterine fibroids were considered as a possible cause. The presence of pelvic discomfort and tenderness further supported this diagnosis.
2. Endometriosis: The patient’s dyspareunia, lower abdominal pain, and irregular bleeding could be indicative of endometriosis. It is important to consider this diagnosis, especially since the patient is sexually active.
3. Pelvic inflammatory disease (PID): Although the patient denied a history of sexually transmitted infections, the presence

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