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Gynecologic Health: Infertility Soap Note

Student's Name

Institutional Affiliation

Course Number and Name

Instructor's Name

Date
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Gynecologic Health: Infertility Soap Note

Patient information

Name initials: AG

Age: 34 years

Ethnicity: White

Gender: Female

Subjective Data

Chief Complaint (CC):

“For the last 4 days I have had immense pain in my lower abdomen, especially when moving my

bowel”

History of Present Illness (HPI):

AG is a White female aged 34 years who visited the clinic alone complaining of immense

pain in her lower abdomen. The pain had persisted for the last 4 days. The pain is worsens upon

moving her bowels and improves upon leaning forward. The patient mentioned that the pain is

equally accompanied by painful instances when having sex. She has been taking painkillers

(Acetaminophen) as a way of alleviating the pain.

Current Medication

The patient has been taking Acetaminophen 500 mg every 6 hours orally.

Allergies
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No identified allergies to drugs or environment

Past Medical and Surgical History

The patient has no existing condition or any surgical history

Reproductive/Sexual History

The patient is a nulligravida and has been in marriage for 6 years.

Gynecologic and Obstetric History

AG mentions not having any previous births (being a nulligravida). Her last day of her

last menstrual cycle was on the 5th of February, 2024. According to the patient, her menses are

regular and lasting for 4 to 6 days per monthly cycle. Heavy menses is experienced during the

first and last day. AG’s indicates instance of painful lower abdomen during her menses. She is

also trying to get pregnant and thus is not on any contraceptives.

Personal History

AG is a public servant employed by the government as a school teacher. She indicates

that this profession is quite demanding and that her role as a teacher causes her stress at times

especially when on her menses due to abdomen pains. Her husband has a vehicle repair garage as

his full time job. Both the patient and her husband live in a rented apartment and they are both

trying to have a child. AG refutes being a smoker and she mentions same case about her

husband.

Immunization

AG is current with all her immunizations, including COVID-19 vaccine of which she

received her second dose and booster shot in November 2023.

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Family History

 The patient’s father has diabetes diagnosed 15 years ago

 Her mother is asthmatic diagnosed in her early 20s

 Her 3 siblings have no major medical issues

 AG’s paternal grandmother is healthy and without any medical problems. Her paternal

grandfather died 2 years ago of liver cirrhosis.

 She does not provide any details about her maternal grandparents

Social Lifestyle

Ms. AG and her husband are fiscally well-off and have taken their family expenses

equally. They love one another but lately her husband has been insisting of adopting a child. This

has brought some form of disagreement between them.

ROS

General: AG refutes fatigue and weight changes

Skin: no itching, sores, dryness, lumps or rashes

HEENT: AG agrees to clear vision, refutes hair changes, and refutes double vision or blurry

vision. She refutes hearing problems. She further refutes dental issues, rhinorrhea, or sore throat.

The patient refutes cough or any pain in her upper respiratory track.

Neck: No neck injury or pain

Respiratory: refutes dyspnea

Cardiovascular: refutes tremors, peripheral edema, or chest pain

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Breasts: refutes breast changes, pain, or breast masses.

Gastrointestinal: indicates severe lower abdominal pain. She further mentions worsening of this

pain during intercourse and during menses.

Peripheral Vascular: Refutes swelling or fatigue

Urinary: the patient refutes having the urge to urinate frequently

Genital: AG indicates vaginal pains when having sexual intercourse. She refutes dysuria,

polyuria and hematuria.

Neurologic: she refutes confiscations or headaches

Musculoskeletal: she refutes muscle detachment muscular weakness or spasms

Psychiatric: refutes depression or mood swings

Endocrine: refutes weight gain, fatigue, irritability, and diarrhoea

Objective Data

Vital signs: Height = 5’6’’, BMI = 28.1 P = 89, R = 18, Wt = 188 lbs., BP = 130/78, T =97.9

Physical Examination

General: AG is alert and without any mood changes or body odor.

Skin: no cyanosis, cyanosis bruises, or edema seen

HEENT: no nasal flare, no dry cough, no throat congestion.

Neck: No bruises or swelling. Midline trachea seen

Chest medium sized and pendulous breasts, with symmetrical nipples.

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Heart/Peripheral Vascular: No peripheral edema or mumbles, rubs or gallop.

Abdomen: non-tender and non-distended,

Musculoskeletal: Her muscle strength 5/5 across all extremes.

Neurological: no seizures with cranial 2-3 Intact

LABS: results of assessed abdominal values

HDL = 60; LDL = 90; Triglycerides= 138 U/A: Ketones 30 mg/dL, Protein 6.5 g/dL FBS=90

mg/dL; HgA1C = 5.5%, BUN = 12 mg/dL, Cholesterol = 198 mg/dL. HCG=negative

Differential Diagnosis

Primary diagnosis

Endometriosis (ICD-10 code: N80.9)

As mentioned by Chauhan et al. (2022), Endometriosis is a severe gynecologic,

inflammatory condition characterized with endometrial-like tissue exterior to the uterus lining

(endometrium) and associated with painful episodes. Women suffering from this condition have

severe and dysmenorrhea pain in their pelvic region. Among the physical symptoms and signs of

this condition are painful menses, abdominal pains, intercourse pains, bowel movement pains,

and infertility (Horne & Missmer, 2022). AG’s symptoms fully mirror the above symptoms of

Endometriosis. Most important is the symptom of infertility, which explains why the patient has

been unsuccessful in getting pregnant. A further lab test is however important in diagnosing this

condition.

Lab test
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The best recommended lad test is laparoscopy, which entails making a minor cut in the

abdomen to insert a tubed light camera that enables the physician to examine the surrounding

tissue for any indications of endometrial tissue growth (Horne & Missmer, 2022).

Pelvic Inflammatory Disease (ICD-10 code: N73.9) (PID)

PID is the infection of the upper reproductive organs, comprising of the fallopian tubes,

the uterus and ovaries (Mitchell et al., 2021). PID symptoms includes inflammation of the upper

genital tract. There is much lower abdominal pain, pelvic pain, vaginal pain, and lower back

pain. This condition is highly associated with highly sexually active women with several

intercourse partners and fail to use protection like condoms (Mitchell et al., 2021). The lab test

for this condition involves taking swabs from the patient’s cervix and vagina and testing for

bacterial infection. A positive diagnosis of this condition involves testing positive for

gonorrhoea, chlamydia, or mycoplasma genitalium. In the case of AG, this lab test came

negative, thus ruling the disease out.

Ovarian Cysts (ICD-10 code: N83.20)

Ovarian Cysts are sac-like sealed structures found in an ovary or on the surface of an

ovary, and filled with a liquid. As mentioned by Lim et al. (2022), the cyst is normally a general

phrase that denotes the liquid-filled structure capable of signifying or not signifying a tumor. The

signs and symptoms include pelvic pains, experiencing pains during intercourse, breast pains,

strange bleeding, vomiting and nausea. AG however doesn’t present breast pains, peculiar

bleeding, vomiting or nausea, which rules out ovarian cysts.

Treatment Plan
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For pain management, AG was prescribed with ibuprofen (anti-inflammatory), two

500mg tablets taken orally every 24 hours with food (to prevent gastrointestinal problems) and

sufficient water. AG was further recommended to have these drugs a day before the onset of her

periods. Additional drugs included estrogen medications such as cenestin 0.45mg every 24 hours

to aid in alleviating hormones bring about the build-up of endometrial tissue (Machado et al.,

2020).

Education

AG was educated on the importance of remaining active when going through period

pains in order to alleviate them. She was further advised on the need to adhere more to a diet of

vegetables, fruits and fish.

Follow up Care

Should her condition fail to improve significantly, AG was advised to revisit the clinic for

check-up.

Reflection

Well, I can confidently argue that the whole undertaking was extremely edifying as I

acquired ample insights from AG as a patient. Her visit gave me an opportunity to effectively

differentiate the primary diagnosis of the list of differential diagnosis. While I was primarily

doubtful of the primary diagnosis, all the tests under guidance of my preceptor nullified my

disbelief. However, in another case, I would advise AG on different risk factors capable of

subjecting her to Endometriosis, including her low body mass, genetic aspects and her

nulligravida condition.
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References
Chauhan, S., More, A., Chauhan, V., & Kathane, A. (2022). Endometriosis: A Review of
Clinical Diagnosis, Treatment, and Pathogenesis. Cureus, 14(9), e28864.
https://doi.org/10.7759/cureus.28864
Horne, A. W., & Missmer, S. A. (2022). Pathophysiology, diagnosis, and management of
endometriosis. BMJ (Clinical research ed.), 379, e070750. https://doi.org/10.1136/bmj-
2022-070750
Lim, W. H., Woods, N., & Lamaro, V. P. (2022). Trends and outcomes of ruptured ovarian
cysts. Postgraduate medical journal, 98(1161), e9. https://doi.org/10.1136/postgradmedj-
2020-138833
Machado, D. E., Alessandra-Perini, J., Menezes de Mendonça, E., Claudino, M. C., Nasciutti, L.
E., Sola-Penna, M., Zancan, P., & Alessandra Perini, J. (2020). Clotrimazole reduces
endometriosis and the estrogen concentration by downregulating
aromatase. Reproduction (Cambridge, England), 159(6), 779–786.
https://doi.org/10.1530/REP-19-0502
Mitchell, C. M., Anyalechi, G. E., Cohen, C. R., Haggerty, C. L., Manhart, L. E., & Hillier, S. L.
(2021). Etiology and Diagnosis of Pelvic Inflammatory Disease: Looking Beyond
Gonorrhea and Chlamydia. The Journal of infectious diseases, 224(12 Suppl 2), S29–
S35. https://doi.org/10.1093/infdis/jiab067