ST Thomas University SOAP for A 40 Year Old Female with Endometriosis Discussion
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Andree Daphnee Renaud.
Focused SOAP Note with Positive and Pertinent Data Only for a 40 Year-Old Female with Endometriosis
Case 3
Patient Information:
Initials: C.P. Age: 40 years old Gender: Female Race: Caucasian
Subjective:
CC (chief complaint): “I have been having severe abdominal pains and cramps, which have become worse when having sexual intercourse for the last two months. During the same time, my
periods have also become considerably heavier.”
HPI: The patient is a 40 year-old Caucasian female who states that the symptoms started two months ago. The pain is located in the lower abdomen and is intermittent. The pain is sharp,
crampy, and becomes worse during menstruation and sex. It is slightly relieved by taking acetaminophen, but comes at any time of the day. The patient rates the pain at 7/10.
Current Medications: Acetaminophen 1 g as needed for pain.
PMHx: Admits to previous admission to the hospital for pneumonia.
Sc Hx: Stays with her husband of fifteen years and two teenage sons. She enjoys cooking, traveling, and hiking. Patient C.P. works as a billing clerk in a local hospital and lives in a middle class
housing complex with all necessary amenities. She only drinks over the weekends when she goes out with her husband.
Family Hx: There is a history of coronary artery disease on her paternal side and type II diabetes mellitus on the maternal side.
ROS:
- GENERAL: She admits to chronic fatigue, chills, occasional fever, and some weight loss.
- GASTROINTESTINAL: Positive for nausea, vomiting, severe abdominal cramps, and painful bowel movements during menstruation.
- GENITOURINARY: Positive for pelvic pain and painful urination at the time of menses.
- MUSCULOSKELETAL: positive for debilitating abdominal cramps.
- HEMATOLOGIC: Heavy menstrual bleeding.
Objective:
Physical Examination
There is severe discomfort and pain during pelvic examination.
Diagnostic Results: Full blood count (WBC 12.0 x 109/L; Hb 11.2 gdl-1), magnetic resonance imaging or MRI (positive for endometriosis in the bladder, ovaries, and Fallopian tubes).
Assessment:
Differential Diagnoses
- Endometriosis (N80.9): The patient displays classic symptoms of endometriosis, which include abdominal cramps and pain, nausea and vomiting, heavy and prolonged menses, pain during intercourse, fatigue, painful micturition, and changed bowel habits (Hammer & McPhee, 2018). The pathophysiology of endometriosis involves growth of endometrial tissue in areas other than the uterine endometrium.
- Chlamydia (A74.9): This is a sexually transmitted infection (STI) that is also a possibility in this case. However, it is unlikely as it usually causes a yellowish or greenish abnormal vaginal discharge (Hammer & McPhee, 2018; Jameson et al., 2018). This is absent in this case.
- Pelvic inflammatory disease or PID (N73.9): This is infection and inflammation of female pelvic structures including the Fallopian tubes and the uterus. It characteristically also causes lower abdominal pain (Hammer & McPhee, 2018; Jameson et al., 2018).
Plan:
- Ibuprofen 400 mg as needed
- Laparoscopic surgery to remove all endometrial tissue
- Warm baths
- Acupuncture
- Health education: Join a support group of women who have had or are having endometriosis. This will help with psychological coping.
References
Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction
to clinical medicine, 8th ed. McGraw-Hill Education.
Jameson, J.L., Fauci, A.S., Kasper, D.L., Hauser, S.L., Longo, D.L., & Loscalzo, J. (Eds)
(2018). Harrison’s principles of internal medicine, 20th ed. McGraw-Hill Education.
