Soap Note Entry Date March 26, 2020 Time 2:00 PM

Soap Notenamejddate03262020time200 Pmage25 Yosexfsubjective

SOAP NOTE Name: J.D. Date: 03/26/2020 Time: 2:00 pm Age: 25 y/o Sex: Female

SUBJECTIVE

Chief Complaint: "I have a lot of pain on my left side, in my lower belly."

History of Present Illness: J.D. is a 25-year-old woman presenting with worsening lower abdominal pain. She reports a history of painful menstrual cramps, typically manageable with Tylenol, but this episode has been significantly worse—rated 6 out of 10, lasting up to five hours, beginning two days prior. The pain is localized but sometimes radiates to her legs and lower back. She describes the pain as debilitating, interfering with daily activities. She employs hot compresses for relief as Tylenol was ineffective. Associated symptoms include nausea, increased urination, and pain during urination. She denies fever, vomiting, or chills.

Past Medical History: No prior illnesses; all immunizations are up to date, including Gardasil. No known allergies or medication intolerances. No history of surgeries or hospitalizations. Family history reveals her father has hypertension; her mother is healthy.

Social History: Employed as a research assistant and pursuing a master's degree in biochemistry. Married, sexually active only with her husband. Uses male condoms for contraception, denies recreational drug use, smoking, or vaping. She reports devout Christianity (Catholic).

Review of Systems: Negative for fever, chills, weight change, chest pain, palpitations, cough, visual changes, ear issues, skin rashes, or sleep disturbance. Positive for nausea, urinary frequency, and dysuria. Gynecologic: regular menses, recent heavy flow, no prior STDs, and a recent negative Pap smear.

OBJECTIVE

Vital Signs: Weight 130 lbs, BMI 21.6, Temp 98.6°F, BP 128/72 mmHg, Height 5’5”, Pulse 91 bpm, Respiration 20/min.

General: Alert, oriented, well-nourished, good hygiene.

Skin: Clear, moist, no rashes or lesions.

Head, Eyes, Ears, Nose, Throat: Normocephalic, pupils equal and reactive, conjunctiva pink, no ear discharge, normal nasal exam, oral cavity moist, no lesions.

Thyroid: Normal size, no nodules.

Cardiovascular: Regular rhythm, no murmurs or gallops.

Respiratory: Clear breath sounds, no dyspnea.

Abdomen: Tenderness on deep palpation in the lower quadrants, no rebound or guarding, bowel sounds present, no hepatosplenomegaly or masses.

Breasts: Symmetrical, tender on palpation, no masses or skin abnormalities.

Genitourinary: Tenderness in lower abdomen, external genitalia normal, no lesions.

Pelvic Exam: Cervix mobile and non-tender, no adnexal masses, ovaries non-palpable, vaginal walls smooth.

Musculoskeletal: Normal gait, no joint tenderness or swelling.

Neurological: Normal speech and sensory perception, no dizziness or seizures.

Psychiatric: Anxious but cooperative, oriented, no signs of depression or suicidal ideation.

Laboratory and Imaging: Pending—CBC, urinalysis with culture, STD screening, pelvic ultrasound.

Paper For Above instruction

The clinical presentation of J.D., a 25-year-old woman with progressive lower abdominal pain and associated urinary symptoms, warrants a comprehensive differential diagnosis process. The primary suspicion is endometriosis, supported by her history of worsening dysmenorrhea, pelvic tenderness, and the absence of signs indicative of more acute or emergent conditions. Endometriosis is a chronic gynecological condition characterized by the presence of endometrial tissue outside the uterine cavity, leading to pain, especially cyclic or non-cyclic pelvic pain, dysmenorrhea, and occasionally urinary or bowel symptoms (Davila, 2018).

The differential diagnoses include ovarian torsion, urinary tract infection (UTI), and appendicitis. Ovarian torsion tends to present with abrupt, severe unilateral lower abdominal pain, often accompanied by nausea and vomiting (Ding, Huang, Hong, 2017). However, the subacute onset over two days without sudden severe pain makes torsion less probable in her case. UTI is another plausible differential, given her urinary frequency and dysuria, along with associated nausea. Urinary infections are common and can mimic other abdominal pathologies but are generally confirmed by urinalysis and culture (Urinary Tract Infection, 2019). Appendicitis, though less likely due to the lack of rebound tenderness or signs of systemic infection, remains a possibility; its presentation varies from diffuse to localized right lower quadrant pain with associated nausea (Appendicitis, 2019).

The plan involves empirical treatment with NSAIDs, specifically ibuprofen 800 mg thrice daily, supplemented with hot compresses for pain management. This regimen aligns with current evidence recommending NSAIDs as first-line therapy in endometriosis to reduce inflammation and pain (Vercellini et al., 2014). The patient is advised to monitor her symptoms and return for follow-up in one week, at which point imaging—pelvic ultrasound—will help confirm the diagnosis. Referral to a gynecologist is essential for further evaluation, including possible laparoscopy, which remains the gold standard for diagnosing endometriosis (Davila, 2018).

Education plays a critical role in management. She should continue hygiene practices like washing genital areas to prevent urinary infections, maintain condom use for contraception, and limit activities that could exacerbate her symptoms. Emphasizing the importance of diet and lifestyle modifications, including increasing fiber intake to prevent constipation, may alleviate some discomfort. Additionally, understanding her condition, expectations, and management options fosters better adherence and mental well-being (Vercellini et al., 2014).

The differential diagnoses are systematically addressed through clinical history, physical examination, laboratory investigations, and imaging. An accurate diagnosis of endometriosis can significantly impact her quality of life and treatment outcomes, underscoring the importance of comprehensive gynecological assessment and appropriate follow-up care.

References

• Davila, W. (2018). Endometriosis. Obstetrics & Gynecology, 132(4), 829–838. https://doi.org/10.1097/AOG.0000000000002834
• Ding, D.-C., Huang, C., & Hong, M.-K. (2017). A review of ovary torsion. Tzu Chi Medical Journal, 29(3), 143–147. https://doi.org/10.4103/tcmj.tcmj_55_17
• Urinary Tract Infection. (2019, January 30). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447
• Appendicitis. (2019, March 18). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/appendicitis/symptoms-causes/syc-20369543
• Vercellini, P., Viganò, P., Somigliana, E., & Fedele, L. (2014). Endometriosis: pathogenesis and treatment. Nature Reviews Endocrinology, 10(5), 261–275. https://doi.org/10.1038/nrendo.2014.47
• Hubbard, J. D. (2018). Pathophysiology and management of endometriosis. The Journal of Obstetrics and Gynaecology, 38(4), 399–408. https://doi.org/10.1080/01443615.2017.1328849
• Berek, J. S., & Novak, A. J. (2021). Berek & Novak’s Gynecology. 16th Edition. Lippincott Williams & Wilkins.
• American College of Obstetricians and Gynecologists. (2018). Practice Bulletin No. 182: Management of Endometriosis. Obstetrics & Gynecology, 131(3), e81–e94. https://doi.org/10.1097/AOG.0000000000002630
• Kiyonaga, N. & Sasaki, M. (2020). Clinical features and management of ovarian torsion. Japanese Journal of Gynecologic and Obstetric Surgery, 78(5), 200–206.
• Mayoclinic Staff. (2020). Endometriosis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/endometriosis/symptoms-causes/syc-20354656