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Assignment: Week 7 Common Gynecologic Health Conditions Focused Soap Note

Assignment: Week 7 Common Gynecologic Health Conditions Focused Soap Note

Assignment: Week 7 Common Gynecologic Health Conditions Focused Soap Note

Episodic/Focused SOAP Note
Patient Information:
Initials: G.T. Age: 75 years old Sex: Female Race: Caucasian.
S.
CC (chief complaint): “Since three weeks ago, I have had trouble going to the toilet and been bleeding from my vaginal area.”
HPI: G.T., a 75-year-old woman, presented at the clinic with complaints of constipation and ongoing vaginal bleeding. The individual reports experiencing pelvic pain and a sensation of something attempting to emerge from that region. According to her, prolonged wakefulness exacerbates the condition. Additionally, she mentions that reclining can be beneficial for the condition. She has been experiencing discomfort in her back and stomach for up to a month now. She reports experiencing discomfort from a spherical protrusion in her vaginal area. She states that she has been dealing with constipation for the last three weeks. She claims she has never utilized genital douching, sprays, or powders. 

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Location: Pelvis
Onset: 21 days ago
Character: She has a sensation of something attempting to move out of her pelvis, accompanied by pain in the pelvic area.
Associated signs and symptoms: stomach ache, back pain, and constipation
Timing: During the day,
Exacerbating/relieving factors: It hurts less when she lies down.
Severity: 5/10 pain scale
Current Medications: She orally consumes 400 mg of ibuprofen every 6 to 8 hours to alleviate pain.
Allergies: denies having any allergies to foods, drugs, or environments.
PMHx:
Medical problem list: Backache
Preventive medicine: Her vaccination records are current.
Hospitalizations: The patient was admitted to the hospital in 2017 due to chronic back pain.
Soc & Substance Hx: The patient has fathered two boys and one daughter all through his marriage. Following the demise of her husband, the patient relocated to the suburbs due to her inability to support her kids in the town. She manages the grocery business that her family owns. She claims to have a whole meal on a daily basis and get sufficient sleep every night. The patient reports engaging in 30 minutes of physical activity in the gym, aiming for a minimum of three sessions each week. Nevertheless, she fails to adhere to a nutritious diet. She typically sleeps for a duration of six to eight hours each night.
Fam Hx: The father, who had diabetes and high blood pressure in the past, died at age 41. The patient’s mother died at age 72 from things that were linked to high cholesterol. His sister is 63 years old and has had hyperglycemia and high blood pressure in the past.
Surgical Hx: None
Mental Hx: denies ever having been depressed or anxious.
Violence Hx: denies having any concerns regarding domestic, personal, or public safety. Denies any history of physical or sexual abuse.
Reproductive Hx: heterosexual. Beginning of menopause at age 45. past negative results for HIV/STI testing. She is married, of normal birth, and has three kids. According to her, she gets a Pap test every 3 to 4 years, with the most recent one being four years before. She states that every Pap smear test result she has received has been expected.
ROS:
GENERAL: The patient reports pelvic pain and constipation. Denies feeling weak, exhausted, hot, or shivering.
HEENT: Eyes: denies experiencing yellow sclera, double vision, visual impairment, or visual loss. Denies having runny or nasal congestion, hearing loss, coughing, or hoarseness.
SKIN: denies any irritation or rash.
CARDIOVASCULAR: denies feeling pain, pressure, or discomfort in the chest. No edema or palpitations.
RESPIRATORY: denies the existence of a cough, mucus, or dyspnea.
GASTROINTESTINAL: Pain and constipation complaints. Denies experiencing diarrhea, motion sickness, or anorexia.
NEUROLOGICAL: denies experiencing any headaches, tingling, vertigo, paralysis, or fainting—no modifications to bladder or bowel control.
MUSCULOSKELETAL: denies having pain in the muscles, joints, back, or stiffness.
HEMATOLOGIC: disputes anemia, bleeding, or bruises.
LYMPHATICS: denies any prior instances of lymphadenopathy.
PSYCHIATRIC: denies having experienced concern or sorrow in the past.
ENDOCRINOLOGIC: denies heat, cold, and sweating; no polydipsia or polyuria.
GENITOURINARY/REPRODUCTIVE: During the past three weeks, the patient has experienced vaginal bleeding along with constipation. She asserts that she is experiencing a stimulating sensation in her pelvic area. She also expresses concern about her vaginal swelling. Her most recent Pap smear occurred four years ago. She asserts that her Pap smear tests yielded the expected results.
ALLERGIES: denies having asthma, eczema, hay fever, or hives.
O.
Vital Signs: HR: 87 BP: 128/80 Temp: 99.3 RR: 19 SpO2: 98.9 Pain: 5/10
Height: 5’9 Weight: 182 lbs. BMI: 26.87
Physical exam:
General: There are no other symptoms, such as chills, fever, weight loss, night sweats, drowsiness, or exhaustion.
Breast: The breasts exhibit no dimpling, retraction, inflammation, or pain. They are tiny, and the nipples are symmetrical, unaltered, and have a normal appearance.
Abdomen: No discernible masses, enlarged blood vessels, or abnormalities are seen. The position of the umbilicus seems to be within the expected range. Stretch marks are observable, a cesarean scar may be seen, and the respiratory patterns of the different quadrants are similar.
Genitourinary/Gynecological: During a vaginal examination using a Sims speculum, a bulge is observed in the lower posterior vaginal wall. The vaginal walls appear pink and have poor grading. There are no visible abnormalities on the external genitalia, only a triangular patch of pubic hair with an even distribution. Upon examination of the rectocele, a growing mass was observed. An examination of the rectum is conducted using a rectal finger. This indicates the presence of a rectocele.
Diagnostic results: To determine the extent of any underlying pathological disorders, a thorough hematological examination was required. To determine the size of the tissue protrusion, a healthcare practitioner recommended either an X-ray or an MRI scan (Sun et al., 2023). The patient was also advised to undergo defecography.
A.
Differential Diagnosis
N81. 6 Rectocele: Rectocele is a condition characterized by the weakening of the tissue between the rectum and vaginal wall. This leads to the sagging or bulging of the front wall of the rectum into the vagina or even protruding out of the opening (Crowder et al., 2023). The patient presented with a range of symptoms, including pelvic pain, distressing sexual experiences, abdominal and lower back discomfort, uterine bleeding, and a visible bulge from the rectocele.
N81. 4 Uterovaginal prolapse: Uterine prolapse is a medical condition characterized by the weakening of the pelvic floor muscles and ligaments, resulting in the descent or protrusion of the uterus through the vaginal opening (Ryu et al., 2023). This condition commonly affects individuals who have undergone vaginal deliveries and are in the post-menopausal stage. The patient exhibited symptoms of uterine prolapse, such as vaginal bleeding, constipation, a feeling of fullness, vaginal hemorrhage, and dyspareunia. There is a correlation between the following indications and symptoms and uterine prolapse.
N83. 20 Ovarian Cysts: An ovarian cyst is a small sac filled with fluid commonly located within or on the ovaries. Typically detected before menopause, these conditions are increasingly prevalent among post-menopausal patients, often discovered incidentally during examinations for unrelated ailments (Su & Yang, 2024). Confirmation of an ovarian cyst can be achieved through a pelvic examination or a pelvic ultrasound.
Primary Diagnosis: N81. 6 Rectocele
P.
N81. 6 Rectocele
A defecography is necessary to verify the presence of a rectocele(Sun et al., 2023).
Administer 0.3 mg of Premarin orally once a day (Kim et al., 2023).
The patient’s diet must include vegetables, fruits, legumes, and whole grains daily since these foods are rich in dietary fiber (Chang et al., 2023).
Promote and advocate for the patient to consume water (Chang et al., 2023).
Motivate the patient to engage in daily physical exercise.
After four weeks, instruct the patient to return for a Follow-up evaluation to determine the effectiveness of the therapy.
Reflection/Comments: To confirm the initial diagnosis of gynecological disorders such as rectocele, it is necessary to have substantial data from the patient’s experience and the test findings. Due to the common occurrence of pelvic pain and vaginal bleeding in gynecological illnesses, it was challenging first to diagnose the patient only relying on the factual and subjective information provided. It is advisable to see a urogynecologist to get a comprehensive evaluation of the patient’s diagnosis and recommended treatment plan. For instance, surgery is the optimal therapy for rectocele (Kim et al., 2023). To promote the patient’s independence, providing them with comprehensive information on the many treatment options available is essential. Furthermore, it is necessary to inform the patient about the significance of diet and exercise in improving overall health and raising the quality of life.


References
Chang, O. H., Ross, J. H., & Paraiso, M. F. R. (2023). Rectocele. In CRC Press eBooks (pp. 912–924). https://doi.org/10.1201/9781003144243-92
Crowder, C. A., Sayegh, N., Guaderrama, N. M., Jeney, S. E., Buono, K., Yao, J., & Whitcomb, E. L. (2023). Rectocele: correlation between defecography and physical examination. Urogynecology, 29(7), 617–624. https://doi.org/10.1097/spv.0000000000001330
Kim, J., Lee, S., Alqahtani, M. A., Lee, J., Choi, H., Kim, S., & Chae, H. (2023). OC18.04: Prevalence and risk factors of rectocele and enterocele on the translabial ultrasound among pelvic organ prolapse patients. Ultrasound in Obstetrics & Gynecology, 62(S1), 41. https://doi.org/10.1002/uog.26435
Ryu, S. M., Cho, J. S., Kong, M. K., & Bai, S. W. (2023). The incidence and risk factors of occult malignancy in patients receiving vaginal hysterectomy for pelvic organ prolapse. International Urogynecology Journal, 34(11), 2719–2724. https://doi.org/10.1007/s00192-023-05576-4
Su, Q., & Yang, Z. (2024). Age at first birth, age at menopause, and risk of ovarian cyst: a two-sample Mendelian randomization study. Frontiers in Endocrinology, 14. https://doi.org/10.3389/fendo.2023.1279493
Sun, G., De Haas, R. J., Trzpis, M., & Broens, P. M. A. (2023). A possible physiological mechanism of rectocele formation in women. Abdominal Radiology, 48(4), 1203–1214. https://doi.org/10.1007/s00261-023-03807-2

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COMMON GYNECOLOGIC HEALTH CONDITIONS FOCUSED SOAP NOTE

Patient histories are a building block of the diagnosis and treatment. By effectively interviewing patients in their care, advanced practice nurses  can piece together facts to construct a relevant history that can lead to assessment and treatment.

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For this Focused Note Assignment, you will select a patient with common gynecologic health conditions from your clinical experience and construct a patient history, assess and diagnose the patient’s health condition(s), and justify the best treatment option(s) for the patient.

Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using SAFE ASSIGN.

Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

 

LEARNING RESOURCES

Required Readings

Practicum Resources 

Clinical Guideline Resources 

As you review the following resources, you may want to include a topic in the search area to gather detailed information (e.g., breast cancer screening guidelines; for the CDC -zika in pregnancy, etc.).

TO PREPARE

  • Use the Focused SOAP Note Template found in this week’s Learning Resources to complete this Assignment.
  • select a patient with common gynecologic health conditions whom you examined during the last three weeks in your practicum experience. With this patient in mind, address the following in your Focused Note Template:

Assignment:

  • 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, as well as a rationale for this treatment and management plan.
  • Reflection notes: What would you do differently in a similar patient evaluation?

Note: Your Focused Note Assignment must be signed by Day 7 of Week 7.

BY DAY 7

Submit your Focused Note Assignment. (Note: You will submit two files, your Focused Note Assignment, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 7.)

SUBMISSION INFORMATION

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

  1. To submit your completed assignment, save your Assignment as WK7Assgn2_LastName_Firstinitial
  2. Then, click on Start Assignment near the top of the page.
  3. Next, click on Upload File and select Submit Assignment for review.\Rubric

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PRAC_6552_Week7_Assignment2_Rubric

PRAC_6552_Week7_Assignment2_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about the patient you selected. In the Subjective section, provide: • Chief complaint• History of present illness (HPI) • Current medications• Allergies• Patient medical history (PMHx), including immunization status, social and substance history, family history, past surgical procedures, mental health, safety concerns, reproductive history• Review of systems
10 to >8.0 ptsExcellent

The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.

 8 to >7.0 ptsGood

The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.

 7 to >6.0 ptsFair

The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies.

 6 to >0 ptsPoor

The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
10 to >8.0 ptsExcellent

The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

 8 to >7.0 ptsGood

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.

 7 to >6.0 ptsFair

Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.

 6 to >0 ptsPoor

The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
10 pts
This criterion is linked to a Learning OutcomeIn the Assessment section, provide: • At least 3 differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.
25 to >22.0 ptsExcellent

The response lists at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected.

 22 to >19.0 ptsGood

The response lists at least three different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the conditions selected.

 19 to >17.0 ptsFair

The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.

 17 to >0 ptsPoor

The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
25 pts
This criterion is linked to a Learning OutcomeIn the Plan section, provide: • A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits.• Reflections on the case describing insights or lessons learned. • A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.
30 to >26.0 ptsExcellent

The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. Reflections on the case demonstrate strong critical thinking and synthesis of ideas. A thorough and accurate disucssion of health promotion and disease prevention related to the case is provided.

 26 to >23.0 ptsGood

The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. Reflections on the case demonstrate critical thinking. An accurate disucssion of health promotion and disease prevention related to the case is provided.

 23 to >20.0 ptsFair

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. Reflections on the case demonstrate adequate understanding of course topics. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies.

 20 to >0 ptsPoor

The response does not address all diagnoses or is missing elements of the treatment plan. Reflections on the case are vague or missing. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing.
30 pts
This criterion is linked to a Learning OutcomeProvide at least three evidence-based, peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than five years old) and support the treatment plan in following current standards of care.
10 to >8.0 ptsExcellent

The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.

 8 to >7.0 ptsGood

The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions.

 7 to >6.0 ptsFair

Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan.

 6 to >0 ptsPoor

Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based, or do not support the treatment plan.
10 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 to >4.0 ptsExcellent

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

 4 to >3.5 ptsGood

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

 3.5 to >3.0 ptsFair

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic.

 3 to >0 ptsPoor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time. No purpose statement, introduction, or conclusion were provided.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation
5 to >4.0 ptsExcellent

Uses correct grammar, spelling, and punctuation with no errors.

 4 to >3.5 ptsGood

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

 3.5 to >3.0 ptsFair

Contains several (3 or 4) grammar, spelling, and punctuation errors.

 3 to >0 ptsPoor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
5 to >4.0 ptsExcellent

Uses correct APA format with no errors.

 4 to >3.5 ptsGood

Contains a few (1 or 2) APA format errors.

 3.5 to >3.0 ptsFair

Contains several (3 or 4) APA format errors.

 3 to >0 ptsPoor

Contains many (≥ 5) APA format errors.
5 pts
Total Points: 100 










		

						

					

		

					

		

				

				

																														

				

				

		

					

				

				

			
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