General Gynecologic Evaluation Paper

General Gynecologic Evaluation Paper

Name

Institute of Affiliation

Professor

Date

Focused SOAP Note Template

Patent information: E.G., 38, female (scenario), unspecified ethnicity

Subjective information:

Chief Complaint: Discussion of contraceptive options

History of Present Illness: 38-year-old female does not want more children and is concerned that she might get pregnant from her current partner has never fathered a child.

Current medications: Vitamin C

Allergies: The patient does not have any drug allergies

Past Medical History: The patient had a surgical procedure done when she was a child. She has exercise-induced asthma, migraines, and IBS.

Soc and Substance Hx: She claims that she does not use alcohol, tobacco, or other recreational drugs General Gynecologic Evaluation Paper.

Farm Hx: Her Maternal grandmother is alive but is reported to have dementia. Subsequently, her maternal grandfather is alive and reported to be suffering from COPD. Unfortunately, both her paternal grandparents died in a car accident. However, her mother is alive, and her medical status presents that she has osteopenia and fibromyalgia. Her father is alive as well and has a history of skin cancer (scenario). Finally, her elder sister and younger brother are both healthy with no medical concerns.

Surgical Hx: The patient underwent a tonsillectomy when she was a child.

Mental Hx: The patient has no history or current mental illness presentations in her medical report.

Violence Hx: The patient has no signs nor has ever reported any instances of violence.

Reproductive Hx: G5 P5 L.C. 6. The patient has had two sexual partners in the last 12 months. They have been together with the most recent one for the past three months, and she claims they are getting serious. The patient has a regular menstrual cycle with regular flows. She uses tampons throughout the day with hourly changes and pads at night, which she changes twice. She has never used any form of contraceptive before, but has used birth control pills occasionally.

ROS:

General: The patient has not reported any current weight loss. She has an average body temperature, has no signs of weakness, and has not reported any fatigue.

HEENT: Eyes: she has not reported any visual deficit, blurred vision, double vision, or yellow sclera. Ears, Nose, Throat: she does not have hearing loss. She is not sneezing, no congestion, runny nose, or sore throat (scenario).

Skin: no rash or itching (scenario)

Cardiovascular: she has not reported any chest pain, pressure, or discomfort. No palpitations or edema (scenario).

Respiratory: she has no signs of shortness of breath, cough, or sputum (scenario).

Gastrointestinal: she has no medical history of anorexia, nausea, vomiting, or diarrhea, and she has no abdominal pain or blood (scenario).

Genitourinary: the patient has not reported signs of dysuria, urinary frequency, or urgency. Pregnancy. LMP has not been reported (scenario).

Neurological: the patient has not reported a headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. She has not indicated any changes in her bowel and bladder control (scenario).

Musculoskeletal: she has not reported muscle pain, back pain, or stiffness (scenario).

Hematologic: the patient has no anemia, bleeding, or bruising (scenario).

Lymphatic: there are no signs of enlarged nodes and no history of splenectomy (scenario).

Psychiatric: the patient has not reported a history of depression or anxiety (scenario).

Endocrinologist: no indication of sweating or cold or heat intolerance. There is no polyuria or polydipsia (scenario) General Gynecologic Evaluation Paper.

Reproductive: refer to the HPI and the reproductive history for further information.

Allergies: she has a history of asthma, no hives, eczema, or rhinitis (scenario).

Objective information

Physical exam: the patient height is 5’7" with a weight of 148 (BMI 23.1), BP 118/72 P68 (scenario).

HEENT: The patient’s head is normocephalic because she has no lesions, bumps, or any form of injury. Her pupils are equal, reactive to light and accommodation, and her tympanic membranes are gray and transparent (scenario). Her nasal passage is clear and has no septal deviation. Finally, the mucus in her mouth is pink and moist.

Diagnostic results:

Neck: supple without adenopathy 

Lungs/CV: Her chest wall is symmetrical, the sounds of her breath are clear to auscultation in all lobes.  

Breast: soft, fibrocystic changes bilaterally,  without masses, dimpling, or discharge  (scenario).

Abed: soft, +BS, no tenderness  (scenario).

VVBSU: the patient has a 1st-degree cystocele (scenario)

Cervix: firm, smooth, porous, without CMT (scenario).  

Uterus: R.V., mobile,  non-tender,  approximately 10 cm (scenario).  

Adnexa: without masses or tenderness (scenario).

Assessment

The patient is healthy enough for many contraceptive procedures such as an intrauterine implant device, tubal ligation, and oral medication.

Plan

I will initiate a conversation with the patient to create a rapport with them to gain their trust as required by the professional code of conduct. Once the patient is comfortable enough, we will discuss the appropriate birth control options (Bloomfield, 2021). At this stage, I will answer any questions she might have about the issue of concern. I will also seek the opinion of the souse about his partner’s choice to get a contraceptive (Amos, 2019. This will allow me to determine if they have come to terms with what the contraceptive means for them as a couple. Finally, I will conduct a test to find out her LMP, request a urine pregnancy test, and take a vaginal swab to screen for sexually transmitted infections, which is a concern because she indicates having two sexual partners within the year.

Diagnostic tests:

HIV test, urine pregnancy test, vaginal swab, and a pelvic evaluation

Education for the patient

I will have to ensure that the patient understands that the contraceptives will not prevent her from contracting an STI. I will also indicate that the only way to prevent STIs is by using condoms, being faithful, and maintaining one sexual partner for both her and her spouse. The patient is a good candidate for birth control pills because she does not have any allergies or takes any medication to counteract the contraceptive effects General Gynecologic Evaluation Paper.

Appropriate methods for birth control for E.G

Since she does not want more children from this point forth, birth control pills will be a tedious task for her, and thus I would rule out the medication procedures. Maintaining the consistency of the pills will be difficult, and when she forgets, she might run the risk of getting pregnant, which is not her wish. Furthermore, long-acting reversible contraception has minimal side effects and is highly effective (Ma, 2020. The LARC procedures contraceptives include implants, intrauterine devices, and tubal ligation.

Implants

They are small plastic rods that emit hormones know as progesterone that prevent a woman from getting pregnant, and they can be effective for up to three years but can be removed at any time the patient desires pregnancy. The known side effect is unpredictable bleeding, whereby some women have heavy flows, and others lack menstrual cycles altogether.

Intrauterine device

The copper IUD has no hormones, which means it does not interfere with the woman’s hormones and can be used for up to 10 years. There are hormone-based IUDs that can be effective for 3-6 years. After that, they can be removed at any time the patient wants to have a child. The contraceptive increases the risk of pelvic inflammation if a person has a preexisting condition, but does not cause its occurrence.

Tubal ligation

This is the sterilization of the most effective way to prevent pregnancy, but it is permanent, and most women regret the decision afterward. However, it can be suitable for my patient if they are sure that they do not desire any more children in the future (Sung, 2019). Additionally, the method does not have any form of side effects.

References

Amos, M. (2019). Contraceptive method choice and spousal communication: Examining the effect of family planning method using an instrumental variable approach. Sexual & Reproductive Health Care, 22, 100458.

Bloomfield, J. G., Crawford, T., & Fisher, M. (2021). Registered nurse’s understanding of academic honesty and the perceived relationship to professional conduct: Findings from a cross-sectional survey conducted in Southeast Asia. Nurse Education Today, 100, 104794.

Ma, R., Cecil, E., Bottle, A., French, R., & Saxena, S. (2020). Impact of a pay-for-performance scheme for long-acting reversible contraceptive (LARC) advice on contraceptive uptake and abortion in British primary care: An interrupted time-series study. PLoS medicine, 17 (9), e1003333.

Sung, S., & Abramovitz, A. (2019). Tubal Ligation General Gynecologic Evaluation Paper.