Soap2

25 Jul Soap2

Below is the patient information and the required things. Attached is the guidelines for this as well. Must also include references.

 

(7)

 

·       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?

 

 

 

Chief Complaint

 

Loss of menstrual cycle

History of Present Illness

36-year-old G7 P 3115 with history of T SVD ×3 and then low-transverse cesarean section in 2007 at 33 weeks secondary to monochorionic monoamniotic twin gestation presents for loss of menstrual cycle. LMP was 02/01/2017. Her periods come every 28 days and last 4-5 days. She is 8 weeks 6 days today with EDD of 11/08/2017 based off of LMP consistent with ultrasound today. She denies any bleeding has a little bit of nausea but nothing that she wants medication for. This was an unplanned pregnancy but is desired. She has been taking prenatal vitamins. She does have a complaint of some constipation. She has been ingesting a lot of protein drinks as well.

Tobacco use: Patient has smoked for 17 years and has decreased to 3 cigarettes per day. She called 1-800 quit recently and they suggested a patch versus gum versus candy.

 

Review of Systems
Constitutional: Negative.
Respiratory: Negative.
Cardiovascular: Negative.
Breast: Negative.
Gastrointestinal: Negative.
Genitourinary: Negative.
Gynecologic: Negative except as documented in history of present illness.
Hematology/Lymphatics: Negative.
Endocrine: Negative.
Immunologic: Negative.
Musculoskeletal: Negative.
Integumentary: Negative.
Neurologic: Negative.
Psychiatric: Negative.

 

 

 

Physical Exam

 

Vitals & Measurements HR: 72 (Peripheral) BP: 93/63 HT: 62 in WT: 158.4 lb BMI: 28.97
Gen.: Alert and oriented, not acute distress
Respiratory: Lungs are clear to auscultation, respirations are nonlabored, breath sounds are equal
Cardiovascular: Regular rate and rhythm
Gastrointestinal: Soft, nontender, nondistended
Abdominal: Nontender nondistended, bowel sounds present,
Genitourinary:
Vagina: Within normal limits
Labia: Within normal limits
Cervix: No cervical motion tenderness, closed
Uterus: Within normal limits
Neurologic: Alert and oriented
Psychiatric: Cooperative, appropriate mood and affect

 

Assessment/Plan

 

1. Amenorrhea Patient had a partial OB nurse consult today and was told that she will need to return in 4 weeks to further discuss genetic counseling. She does desire first trimester genetic screening. She was advised to encouraged to continue prenatal vitamins. sHe was advised her expected weight gain goal of 25-35 pounds this pregnancy. She was also encouraged to make sure that she has at least 30 minutes of exercise daily. pap and other first trimester labs obtained today.

 

Ordered:

 

76856 us pelvic nonobstetric real-time image complete. Secondary amenorrhea

 

2. Constipation Patient given a prescription for Colace she was also advised to not do protein shakes in place of an actual healthy diet

 

3. History of low vertical cesarean section Performed in 2007 at 33 weeks secondary to monochorionic monoamniotic twins at 33 weeks. One layer closure with chromic. The patient does desire VBAC. Discussed options of TOLAC with VBAC vs repeat cesarean section. Risks of VBAC include: risk of uterine rupture 0.5-1% which increases to 2-3% with augmentation. This will need to be discussed at future visits as she approaches term

 

Orders:

 

docusate, 1 cap(s) ( 100 mg ), PO, BID, PRN: for constipation, # 60 cap(s), 10 Refill(s),

 

urnls dip stick/tablet rgnt auto w/o microscopy,Amenorrhea

 

ABO/Rh , Amenorrhea

 

Antibody Screen, Amenorrhea

 

CBC w/Diff/Plt Amenorrhea

 

Hgb A1c, Amenorrhea

 

Rubella Antibody IgG, Amenorrhea