NR 602 Week7 SOAP -Lower Abdominal Pain

NR 602 Week7 SOAP -Lower Abdominal Pain

NR 602 Week7 SOAP -Lower Abdominal Pain

K.F. 38yo, F, Latino

S.

CC- Nausea and lower abdominal pain

HPI- The nausea and continuous mild abdominal pain have been present for about 2 weeks, but worsening slightly and now she has developed myalgia and fatigue. She rates the pain 4 on a 1-10 scale. She denies cramping. Reports the pain as “a dull ache”. She has not had a fever, diarrhea, dysuria, rash, headache, blurred vision, and no other household members are ill. She is not taking any current medications. She has been able to eat and drink with some limitations. She has vomited on two occasions, once each week of the abdominal pain. Her LNMP was 10 weeks ago, and she has a history of irregular periods and PCOS, so this pattern is not unusual. She reports she is not currently sexually active and has only been sexually active with her husband whom she is separated from. Her last timing of sexual intercourse was 8 weeks ago, with her estranged husband after a meeting to resolve their separation.

Medications: Tylenol PRN pain, OTC, 1 gram.

Allergies: NKA

PMH: G-4, T-2, P-1, A-1, L-2; cesarean section X 2; no trauma history; 10 year 1PPD smoker, smoking cessation 2 years ago; gestational diabetes with last pregnancy; history of PCOS.

Social History: She continues to live with her parents and is working part time at the children’s school library. She reports her divorce will be final in a matter of a few weeks.

Family history- Maternal and paternal parents are smokers. The mother has been one since age 22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no diseases reported in either parent. Mother has a history with gestational diabetes and preeclampsia.  MGM has a history of hyperlipidemia, Type 2 DM, and Hypertension. They are Latin American in descent, emigrated from Cuba in the 1970s. MGF has a history of hypertension, hyperlipidemia, and an MI with stenting 2 years ago.  The mother has two siblings; one who died in an MVA 5 years ago at the age of 18 a younger brother, and an older sister who is 42 and lives in a large urban city in the Midwest with her family, and she is in good health. Other family members died of old age. She is unaware of paternal familial health history.

NR 602 Week7 SOAP -Lower Abdominal Pain

ROS:

Constitutional- Reports Fatigue.

 

HEENT- Not reported.

 

Skin-  Not reported.

 

Cardiovascular- Not reported.

 

Respiratory- Not reported.

 

Gastrointestinal- Reports nausea and lower abdominal pain “dull ache”. Vomited on 2 occasions.

 

Genitourinary- Reports LNMP was 10 weeks ago, and she has a history of irregular periods and PCOS.

 

Neurological- Not reported.

 

Musculoskeletal- Reports myalgia.

 

Hematological- Not reported.

 

Lymphatics- Not reported.

 

Psychiatric- Not reported.

 

Endocrine- Not reported.

NR 602 Week7 SOAP -Lower Abdominal Pain

O.

Vital Signs: Height: 160 centimeters Weight: 73 kilograms B/P:140/68, T: 99, HR: 92, Resp: 16, reg, non-labored, SpO2: 99%    BMI: 28.5

General: Awake, alert, appropriate; well groomed; tearful at times throughout the exam; skin: warm, dry, intact; HEENT: head normocephalic; Conjunctiva clear, non-icteric, PERRLA, EOM’s intact; tympanic membranes intact, unremarkable; nares patent, unremarkable bilateral; pharynx unremarkable tonsils 2/4 bilateral; neck supple w/o lymphadenopathy.

Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and unlabored.

Abdominal: abdomen, soft, with normoactive bowel sounds throughout; tenderness to palpation in the super-pubic area; no masses or organomegally; peripheral pulses reg., equal.

Genitourinary: pelvic exam reveals pink vaginal mucosa with a moderate whitish-clear discharge. Cervical os is mildly injected and easily friable; she is exceedingly tender to palpation, particularly cervical motion tenderness and her uterus is enlarged to about the size of a softball.  Labia majora and minora intact without lesion.

Urinalysis in the office: Cloudy amber yellow urine, Sp. Gr. 1.010, positive WBCs, but no nitrites or leukoesterase; negative for RBCs, glucose, and ketones

Chlamydia and Gonorrhea vaginal cultures sent.

STD Lab Results  

Patient: Kayla Smith

Acc #: 12345

Patient #: 123456KS Birth: 6/18/1987 Collection Date: 11/04/2013 Doctor: NON-STAFF Age: 26 years Received in Lab: 11/04/2013 Home Phone: (301)123-4567 Gender: Female DR SMITH

Test Name Result Flag Reference Interval Lab Chlamydia/GC Amplification

Chlamydia trachomatis, NAA Positive Abnormal

Neisseria gonorrheae, NAA Negative

Urine Pregnancy Test—Positive

A.

Primary Diagnosis:

Pregnant state, incidental (Z33.1) – Urine pregnancy test is positive. (Fenstermacher & Hudson, 2016) Kayla’s urine pregnancy test was positive.

Secondary Diagnosis:

Chlamydia (A74.9) – Chlamydia trachomatis is the leading cause of infertility, ectopic pregnancy and pelvic inflammatory disease. Symptoms may be asymptomatic with mild dyspareunia, mucopurulent cervicitis or vaginal discharge with spotting after sex and pelvic pain. Exam reveals cervical motion tenderness with purulent discharge from cervix; the cervix appears friable with erosions and irritation (Fenstermacher & Hudson, 2016). Kayla has moderate whitish-clear discharge, cervical os is mildly injected and easily friable; she is exceedingly tender to palpation, particularly cervical motion tenderness. Along with a positive Chlamydia test.

Pelvic inflammatory disease, unspecified (N73.9) – This is a vaginal infection that causes abdominal pain, uterine tenderness, abnormal cervical or vaginal mucopurulent discharge, and cervical motion tenderness (Schuiling & Likis, 2013). Kayla is having lower abdominal pain with injected and easily friable cervix and cervical motion tenderness. Chlamydia and Gonorrhea vaginal cultures sent.

Cervical dysplasia (N87.0) – Kayla has ASCUS which stands for atypical cell of undetermined significance, she has abnormal cervical cells. With this result the provider should next check for the presents of the virus human papillomavirus (HPV) (Fontaine, Saslow, & King, 2012). Kayla still had not gone to the OB/GYN about her abnormal cervical cells.

NR 602 Week7 SOAP -Lower Abdominal Pain

Differential Diagnosis:

…

P.

Diagnostics:

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Education

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References

Centers for Disease Control and Prevention (CDC). (2015, June 4). Gonococcal infections. Retireved from http://www.cdc.gov/std/tg2015/gonorrhea.htm.

Epocrates. (2015). Zithromycin. Retrieved from https://online.epocrates.com/rxmain.

Epocrates. (2015). Ceftriaxone. Retrieved from https://online.epocrates.com/rxmain.

Epocrates. (2015). Prenatal vitamin. Retrieved from https://online.epocrates.com/rxmain.

Fenstermacher, K. & Hundson, B. T. (2016). Practice Guidelines for Family Nurse Practitioners (4th ed.). St. Louis, MO: Elsevier.

Fontaine, P. L., Saslow, D., & King, V. J. (2012, September 15). ACS/ASCCP/ASCP guidelines for the early detection of cervical cancer. American Family Physician, 86(6), 501-508.

Jucktee, G. & Hartman-Adams, H. (2010, November 15). Human papillomavirus: clinical manifestations and prevention. American Family Physician, 82(10), 1209-1214.

Mayor, M., Roett, M. A., & Uduhiri, K. A. (2012, November 15). Diagnosis and management of gonococcal infections. American Family Physicians, 86(10), 931-938.

Mishori, R., McClaskey, E. L., & Winklerprins, V. J. (2012, December 15). Chlamydia trachomatis infections: screening, diagnosis, and management. American Family Physician, 86(12), 1127-1132.

Moss, D. A., Snyder, M. J., & Lin, L. (2015, April 15). Options for women with unintended pregnancy. American Family Physician, 91(8), 544-549.

Schuiling, K. & Likis, F. (2013). Women’s gynecologic health (Second ed.). Burlington, MA: Jones & Bartlett Learning, LLC.

Zolotor, A. J. & Carlough, M. C. (2014, Feburary 1). Update on prenatal care. American Family Physician, 89(3), 199-208.