ADVANCED P NR509 SOAP Note Women's health exam study guide

SOAP Note Women’s Health Patient Information: Initials A.P Age 31 Sex Female Race Caucasian Insurance Blue Cross Blue Shield S. Chief Complaint (CC): A.P. is a 31-year-old Caucasian female presented to the clinic with the chief complains of 5 years of the irregular menstrual cycle, pelvic pain that started about a year ago with increased intensity and length for about a month, and acute onset of burning on urination started about 2 weeks ago. A.P. reported to live with her boyfriend and is sexually active for last 5 years. HPI: A.P is a 31-year-old female presented with the long history of the irregular menstrual cycle, chronic pelvic pain, and new onset of burning urination. A. P. had her menarche at age 13 years of age and her menstrual cycle was regular. Since last 5 years, her menstrual cycle has been irregular. She reported having her cycle once every 2 to 4 month with heavy menstrual flow and dysmenorrhea. She was started on the oral contraceptive pill for her abnormal menstrual cycle, menorrhagia, and dysmenorrhea which she tried for about a year. It helped to regulate her cycle but she gained weight abruptly and had mood change so she decided to stop it. After she stopped taking birth control pill her symptoms came back. She hasn’t seen the OBGYN for 2 years. She also reported few episodes of a headache and nausea and had done multiple home pregnancy tests which have been negative. The last home pregnancy did four days ago was negative. She also reported having intermittent pain in the pelvic region which has been going on for about a year. She explains the pain as mild to moderate dull aching pain, rated 3-5 in the scale of 0-10, around the pelvic and lower abdomen, worsened during and after sex. The Hot top bath helps her to relax and relieve some of the symptoms. She reported to have increased frequency of pelvic pain and new onset of burning on urination for last 2 weeks which she is worried about possible infection or illness, therefore she decided to visit the clinic. She denies fever, frequency, urgency, foul smell, flank pain, or local soreness. The burning sensation is so severe that she needs to sit or run cool water after she voids. Drinking plenty of fluids and cool water makes her feel better. She denied using other medical remedies to treat the symptoms. Irregular menstrual cycle Onset: 5 years ago Location: vagina/uterus Duration: Once every 2-4 months followed by dysmenorrhea and menorrhagia which last for 7 to 10 days. This study source was downloaded by from CourseH on :52:57 GMT -05:00 Characteristics: Menstrual cycle happens once in every 2-4 month which begins with spotting and moderate to severe cramps that last for a day or two which turn into a heavy flow with clots that are about dime size which last for 6 to 8 days. Aggravating Factors: stress or anxiety Relieving Factors: Contraceptives pills helped to regulate her cycle in the past otherwise haven’t tried other remedies. Rest helps to soothe the cramps. Treatment: Ibuprofen PRN for menstrual