NRNP 6552: Advanced Nurse Practice in Reproductive Health Care PRAC 6552 Week 7 Assignment 2: FNP Students OB Episodic Visit: Focused Note (ACCURATE 2024 SPRING QTR) Episodic/Focused SOAP Note Template Week 5/Case Study D.M. is a 52 -year-old African American, G2T1P0A1L1 female presenting to the clinic with complaints of abnormal bleeding and pelvic pressure. She works full -time as a receptionist for Gunn Honda. Medical history includes Grave disease, anemia, CAD, hypertension, obesity, and osteopenia. Surgical history includes D&C, tubal ligation, endometrial biopsy (in office). She currently takes metoprolol, aspirin, progestin mini pills, and iron. She is aller gic to PCN. Family history, Mother has a history of hypertension and obesity, alive and 75, Father passed away from MI at 57. Social history is negative for illicit drug use or smoking, she reports having 1-2 glasses of wine/week. GYN history, the onset of menses age 14, heavy bleeding, menses irregular since age 48. She has some cramping and pelvic pain and pressure with menses. She lives a sedentary lifestyle, minimal exercise 1 -2 times a week, wears seatbelts when i n the car, denies texting and driving. She reports she has been bleeding for 14 days. Patient Information: D. M., 52, Female, African American S. CC (chief complaint): Abnormal vaginal bleeding HPI: 52-year-old African American, G2T1P0L1, presents to the OBGYN complaints of abnormal bleeding and pelvic pressure. Patient has a history of menorrhagia and dysmenorrhea, reports bleeding for over 14 days. Location: Vagina Onset: Intermittently, 6 months ago Character: Bleeding, pelvic pressure Associated signs and symptoms: Heavy menstruation, cramping, bloating Timing: During, before, and after menstruation Exacerbating/relieving factors: Ibuprofen helps Severity: 6 -7/10 pain scale Current Medications: 1. Metoprolol 25mg qd 2. Aspirin 81mg qd 3. Iron Ferrous Sulfa te 65mg, bid daily 4. Camila, Progestin -only mini qd NRNP 6552: Advanced Nurse Practice in Reproductive Health Care 5. Ibuprofen prn Allergies: Penicillin PMHx : Grave disease, anemia, coronary artery disease (CAD), hypertension, obesity, and osteopenia. Last Tdap 2014, Influenza Vaccine received 09/18/2020. Hospitalizations for childbirth and surgical procedures. Soc & Substance Hx : D.M. has been married for 17 years. Social history is negative for illicit drug use or smoking, she reports hav ing 1 -2 glasses of wine/week. She uses safe driving practices by wearing her seat. She lives in a home together with her husband and has a 28-year- old son. Minimal exercise 1-2 times a week Fam Hx: No history known of her fraternal and maternal grandpare nts. Her mother is alive with hypertension and obesity, and her dad is deceased, myocardial infarction at age 57. She has one older sister with hypertension, and one younger brother with no medical problems. Surgical Hx: Dilation & curettage 2000, tubal ligation 2000 Mental Hx: Denies a history of anxiety, depression, or any other mental health history. No sleep problems, delusions, or suicidal thoughts. Violence Hx: Denies concerns or issues about safety in personal, home, community, or sexual, current and past Reproductive Hx: LMP 9/10/2020, G2P1LC1, menarche at age 14, cramping, pelvic pain and pressure with menses. Progestin mini pill to help menorrhagia. Spontaneous abortion 2000. Reports irregular menses since age 48. ROS: GENERAL : Reports fatigue. Denies recent fever, chills, or night sweats. No recent weight gain or loss of significance. HEENT: Head: Normocephalic Eyes: Denies change in vision, sclerae white, reports no changes in eyes, denies glaucoma, double vision, floaters, excessive tearing, or dryness. Ears: Denies hearing loss, no recent ear infections, pain, tenderness, tinnitus, or discharge from ears. Nose: Denies history of nasal polyps, denies sneezing congestion, runny nose Throat: denies sore throat. Last dental exam, August 2020, denies oral lesions, bleeding gums, or gingivitis. Denies any problems with chewing or swallowing. SKIN: Denies rashes, itching, lesions, open sores, or bruising. Denies history of cancer. CARDIOVASCULAR: Denies chest discomfort, palpitations, edema or a heart murmur. RESPIRATORY: Denies dyspnea, cough, sputum production, or hemoptysis.
