Gynecological Disorders Soap Note

 Gynecological Disorders Soap Note

Week 7

Case Study 1:

R.B. 95-year-old, white male, currently living in a skilled nursing facility (SNF)

Chief complaint: “My urine is really red.”

HPI: On Wednesday (2 days ago) the patient was brought to your clinic by his son and complained that his urine appeared to be bright red in color. You ordered labs, urinalysis, culture, and sensitivity, and the results are below.

Allergies: Penicillin: Hives

Medications: Tamsulosin 0.4 mcg, 2 capsules daily, Aspirin 325 mg daily, Atorvastatin 10 mg 1 tablet daily, Donepezil 10 mg 1 tablet PO QHS, Metoprolol 25 mg 0.5 mg tablet every 12 hours, Acetaminophen 500 mg 1 tablet BID

Code status: DNR  Regular diet, pureed texture, honey-thickened liquids

Vitals: BP 122/70, HR 66, Temp 98.0 F, Resp 18, Pulse ox 98%

PMH: Cognitive communication deficit, pneumonitis due to inhalation of food and vomit, dysphagia, R-side hemiplegia and hemiparesis past ischemic CVA, moderate vascular dementia, malignant neoplasm of prostate, new-onset atrial fibrillation (12/2019), DVT on left lower extremity, gross hematuria

Labs:

RBC                         3.53 (L)

Hemoglobin           10.2 (L)

Microscopic Analysis, Urine, straight cath

Component:

WBC UA                                      42 (H)              (0-5/ HPF)

RBC, UA                                      >900 (H)  (0-5/HPF)

Epithelial cells, urine                2                    (0-4 /HPF)

Hyaline casts, UA                     0                    (0-2 /LPF)

Urinalysis

Color  Red

Appearance (Urine)       Clear

Ketones, UA                  Trace

Specific gravity             1.020                   (1.005-1.025)

Blood, UA                      Large

PH, Urine                       7.0        (5.0-8.0)

Leukocytes                    Small

Nitrites                          Positive

C&S results were not available yet.

Assignment: Assessing, Diagnosing, and Treating Abdominal, Urological, and Gynecological Disorders

Photo Credit: Teodor Lazarev / Adobe Stock

Accurate history taking of abdominal, urological, and gynecological complaints is essential for completing an assessment of the older adult. For this Assignment, as you examine this week’s patient case study, consider how you might evaluate and treat older adult patients who present with health concerns related to the abdominal, urological, or gynecological systems.

To prepare:

  • Review the case study provided by your Instructor.
  • Reflect on the patient’s symptoms and aspects of disorders that may be present.
  • Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
  • Access the Focused SOAP Note Template in this week’s Resources.

The Assignment:

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

  • Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
  • Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
  • Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
  • Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Abdominal disorders. In Advanced practice nursing in the care of older adults (2nd ed., pp. 225–279). F. A. Davis.

Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Urological and gynecological disorders. In Advanced practice nursing in the care of older adults (2nd ed., pp. 280–304). F. A. Davis.

Demarest, L. (2019). Gotta go right now: What’s overactive bladder? Nursing Made Incredibly Easy!, 17(4), 11–14. https://doi.org/10.1097/01.NME.0000559586.35631.37

Jackson, P., & Vigiola, C. M. (2018). Intestinal obstruction: Evaluation and management. American Family Physician, 98(6), 362–367.

Shian, B., & Larson, S. T. (2018). Abdominal wall pain: Clinical evaluation, differential diagnosis, and treatment. American Family Physician, 98(7), 429–436.

Document: Focused SOAP Note Template (Word Document)

Recommended Reading (click to expand/reduce)

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We are a professional custom writing website. If you have searched for a question and bumped into our website just know you are in the right place to get help with your coursework.

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  • Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

  • Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

  • APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

  • Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

  • LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

  • Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

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Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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