SOAP Note Assignment
Name
Department
Course
Date
SOAP Note Assignment
Patient Information
EG, 38 y/o, F, Caucasian
S.
CC: Contraceptive Counselling
HPI
A 38-year-old white female presents for counseling on birth control. The woman wants to start using contraceptives, although her current partner has never had a child. She does not prefer oral contraceptives as she did not follow prescriptions in the past.
Current Medications
Vitamin: C
PMH: Migraines, Exercise-induced Asthma and IBS
Surgical History: Tonsillectomy in childhood
Substance History: No use of alcohol, tobacco or any other recreational drugs
Family Health History:
Maternal grandmother alive with Dementia
Maternal grandfather alive with COPD
Mother alive with two conditions: osteopenia and fibromyalgia
The father has basal cell
Her siblings lack any medical complications
Reproductive History:
G5 P5 LC 6
Not interested in conceiving again
Partner has not sired children before.
Objective
Height 5’7 Weight 148(BMI: 23.1) BP 118/72 P68
HEENT: Within normal limits
Lungs/CV: wnl
SOAP note assignmentBreast:
Soft
Fibrocystic changes bilaterally
No masses
Dimpling and discharge absent
Abdomen: +BS, no tenderness
WBSU: wnl except for 1st-degree cystocele
Reproductive:
WBSU: Within the normal limit
1st-degree cystocele
Cervix: Firm, smooth, non-tender, approx. 10 cm
Adnexa: without masses or tenderness
Diagnostic results:
Pap and Pelvis Tests
Pap and pelvic tests are highly recommended before the use of contraceptives. According to (Urrutia et al., 2017), many women avoid pap tests despite their importance in sexual health. The pap test seeks to determine the possibility of cervix cancer before the administration of oral contraceptives. On the other hand, the tests on the effect of Sulphur based contraceptives are to be considered. Finally, a pregnancy test must be conducted as the use of contraceptives during pregnancy is not advised.
BMI Test
In some cases, some contraceptives cause an increase in weight. According to ( San- Juan- Rodriguez et al.,2020), hormonal contraceptives restrict weight gain. The patient may want to consider the effect of each contraceptive on the effect on weight. For instance, she has a BMI of 23.1. BMI above 25 is unhealthy. Therefore, she should decide on the contraceptive from the point of knowledge.
SOAP note assignmentHormone Imbalance Test
Contraceptive pills contain hormones such as estrogen. In addition, it can be caused by hormonal therapy(Aftab & Khan, 2018). The hormones can lead to the formation of fibroids in the uterus if not kept under check. Additionally, contraceptive pills and patches can cause a rise in blood pressure in some women. Consequently, the chances of developing hypertension are on the rise. Therefore she must know the possible side effect of each contraceptive.
Assessment
1
Cluster headaches
Migraines are the premonitory phase of cluster headaches. The condition may not have developed to the prodromal phase. The migraine, a pre-attack syndrome, facilitates the abortive treatment of cluster headaches. (Snoer et al.,2018)
2
Fibrocystic Breast
Fibrocystic changes indicate the development of fibrocystic breast. besides the changes, the presence of lumps, abscesses, and fibroadenomas can lead to the general diagnosis. (Malherbe & Fatima ,2019)
SOAP note assignment
Contraceptive options
Skyla IUD: is a type of LNG-IUD. It is recommended for patients whose spouses are not siring children. Since it works by making mucus in the vagina thick, withdrawal restores fertility almost immediately.
Mirena IUD: it is similar to Syla and works almost identically. In this case, it is highly recommended as the patient does not prefer oral contraceptives. According to (Veisi et al.,2017), Mirena IUD can be used as an effective birth control method by women.
Plan
A pregnancy test will be conducted, and BMI/BP will be sought
Insertion of Mirena IUD will ease the cluster headaches, which are a side effect of oral pills. Besides offering relief, the IUD will prevent pregnancy as well.
Information on the available contraceptive options should be given to the patient. Assuming she chooses Mirena, specific information should be given to the patient. The contraceptive will be effective after a week.
Disposition: The patient will be discharged with annual checkups except