VANESSA Masikhwa 1865639 BCMP year 2 oogyn rotation

VANESSA MASIKHWA

BCMP YEAR 2

SOAP NOTE

1865639

OBOGYN ROTATION

Patient data

Name Mrs vt

Age 25

Gender female

Hospital number GP 0798654

Place bheki mlangeni district hospital

Date 12 September 2019

Time 09 :00am

Subjective 

Chief complaint

“2 weeks of menstruation

Mrs vt is 25 year old female who presented with 2 weeks of unending menstruation since the 30th of August, this  started after she had a ctop(2 months) done as she did not feel ready to have a child . The blood is always coming out and never stop  she has not tired taking anything for it as she did not know where to start and what was causing it .

the blood is mostly red like her normal menstrual  but since the 10 I’m the mornings the blood is a bit dark and has more clots  than off ten it has started to smell offensive .when in her normal menstrual cycle that wound normally last 3 to 5 days and was constant and never skipped months or had extra days  she wound change her sanitary pad 3 times a day but if she had eaten if she would change it 5 times she reports not knowing what is the connection between her periods and her eating adding that it just happens .

Now since the 30th of August she has been changing her pad for the 4 times a day and has not eaten any fish this month and that might have caused her period to be prolong . When she had the ctop  done she was told she was going to bleed for a week at most and it has been 2 weeks and now she is worried .

Get quality help now
Prof. Finch
Verified

Proficient in: Cancer

4.7 (346)

“ This writer never make an mistake for me always deliver long before due date. Am telling you man this writer is absolutely the best. ”

+84 relevant experts are online
Hire writer

She is a proud mother of a  3 year old girl who she leaves with  For that past week  she had been more tired and find it hard to concentrate on her day to day tasks like cleaning and her assignment as she is a part time students at unisa.

She has no known allergies ,she has no bleeding disorders and no one in her family has bleeding disorders he has not had any surgery on her uterus  ( the scar may bleed as  manual vacuum aspiration may have opened the scar and caused her bleeding ).  She has no history of stis but has had 3 fungal infection for the past year and a half she uses antifungal creams that she gets at her local clinic  has had a Hertfordshire  last normal menstrual period was on the 20th of may 2019 she has a gravity of 1 and parity of 2 and 1 miscarriage. She is hive negative ,she does not drink or smoke

Objectives

The patient looks clinical stable but worries about her menstruation as she constantly looking at her pants and keep her distance.

Vitals

Respiratory rate 20 bpm eupnoea

Heart rate 115 bpm eucardia

Blood pressure 135/75 mmhg

Temperature 36.5 normothermia

JACCOLD

No jaundice

Anemia

No cladding

No cyanosis

No oedema

No lymphedema

Dehydration take 5 seconds to return

Pv

Inspection

The patient has no scares ,lessons, excoriations, unusual pigmentation ,patient has no public as it is shaved ,no swelling of the labia majora,clitrous is pink ,labia minora is darker  and most ,vaginal opening sufficient and not swelling

Palpation

No swelling and lumps

Speculum examination the cervix could not properly as was covered in blood

Biannual examination

Cervical tenderness present, smooth round and firm

The uterus is midpostionaround 10 to 14 cm in size 

Cardiovascular exam

Inspection

No Scars

No visible apex bite

No lymphedema

Conjunctival pallor

Palpation

Apex bit felt in correct anatomical position

Capillary refill takes 3 seconds

Auscultation

S1 ,S2 no S3

Respiratory exam

Inspection

Not in any distress as there is no use on accessory muscles

Palpation

No lymphedema

Mild vibrations 3-1-3 regions anterior and posterior

Percussion

Mild resonance 3-1-3 regions anterior and posterior

Auscultation

Good air entry bilaterally

Investigations

Hb 8.5

Full blood count (results pending ), in for any clotting disorder, I would expect to see signs of  hemolytic anemia like decreased Hb,

Ultrasound

The ultrasound showed no fetal remains and placenta was also completely removes but there was a calcified mass  found on the fundamental of the uterus it is about 5 to 8 cm

Fine needle biopsy results pending this is to check if the mass is cancerous

Assessment

No final diagnoses has put is place these are working diagnoses

Biological

Uterine fibroids

Uterine cancer

 Psychological – social

The patient seems stressed about the menstruation abouts it reminds her of the choice  she made to terminate her pregnancy

Plan

Admit to ward to gynecological ward as the was following a ctop and cause of bleeding was not fully understood

To administer normal saline 250 ml, 125 ml per hour(for dehydration)

Iron supplements 5mg once a day with meals (low hb)

Co Trimoxazole 80/400 mg oral once at night (profelases incase on infection)

Educate patient about contraception

To advice about diet and eating iron rich foods

Refer to psychological about ctop and the worries she has

 

Cite this page

VANESSA Masikhwa 1865639 BCMP year 2 oogyn rotation. (2019, Dec 11). Retrieved from http://paperap.com/vanessa-masikhwa-1865639-bcmp-year-2-oogyn-rotation-best-essay/

Let’s chat?  We're online 24/7