urgent focus note

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Comprehensive Well-Woman Paper History and Physical Soap Note

Student

Instructor

University affiliation

Class Name

Date

SUBJECTIVE DATA (S)

Initials: J.D.

Age: 32

Race: Caucasian

Gender: Female

Marital Status: Married

Informant: Patient

CHIEF COMPLAINT (CC):

"I have been experiencing persistent lower abdominal pain for the past week."

HISTORY OF PRESENT ILLNESS (HPI):

· Location:

Lower abdomen, bilateral

· Quality:

Dull and cramping pain

· Severity:

6/10 on pain scale

· Timing:

Started one week ago, intermittent

· Setting:

Occurs mainly after meals and at night

· Alleviating and aggravating factors:

Worse after eating fatty foods, improved with rest and warm compress

· Associated signs and symptoms:

Occasional nausea, no vomiting, no fever, no change in bowel habits (Fanslow et al., 2019).

PAST MEDICAL HISTORY (PMH):

· Allergies:

No known drug allergies

· Current medications:

Ibuprofen PRN for pain, daily multivitamin

· Age/Health Status:

32, generally healthy

· Immunization Status:

Up to date

· Previous screening tests:

Normal Pap smear (2023), normal lipid panel (2022) (Lakhoo et al., 2021)

· Childhood illnesses:

None significant

· Major adult illnesses:

None reported

· Injuries:

None significant

· Hospitalizations:

None

· Surgeries:

Appendectomy (2015)

FAMILY HISTORY (FH):

· Mother: Alive, 58, history of hypertension

· Father: Deceased, heart disease at age 60

· Siblings: One brother, healthy

· No known family history of cancer, diabetes, or autoimmune diseases

SOCIAL HISTORY (SH):

· Marital Status:

Married, lives with spouse

· Occupation:

Office manager

· Exercise:

Walks 3x per week

· Diet:

Balanced but high in fried foods

· Substance Use:

No smoking, occasional alcohol

· Living Arrangements:

Lives in a suburban home

· Safety:

Uses seatbelt regularly, no firearms at home

· Reproductive History:

LMP 12 days ago, regular cycles, gravida 2 para 1

· Sexual History:

Heterosexual, monogamous, no known STIs

REVIEW OF SYSTEMS (ROS):

1. Constitutional:

No fever, no weight changes

2. Eyes:

No vision changes

3. Ears, Nose, Mouth, Throat:

No ear pain, nasal congestion, or sore throat

4. Cardiovascular:

No chest pain, palpitations, or edema

5. Respiratory:

No cough, dyspnea, or wheezing

6. Gastrointestinal:

Lower abdominal pain, occasional nausea, no vomiting or diarrhea

7. Genitourinary:

No dysuria, urgency, or hematuria

8. Musculoskeletal:

No joint pain or swelling

9. Integumentary:

No rashes, lesions, or changes in skin

10. Neurologic:

No headaches, dizziness, or weakness

11. Psychiatric:

No anxiety or depression

12. Endocrine:

No heat/cold intolerance

13. Hematologic/Lymphatic:

No easy bruising or bleeding

14. Allergic/Immunologic:

No known allergies or immune deficiencies

OBJECTIVE DATA (O):

1. Constitutional:

VS: Temp 98.6F,

BP 120/76,

HR 78,

RR 16,

Height 5'6",

Weight 150 lbs

Well-appearing, no distress

2. Eyes:

PERRLA, EOMI, no conjunctival injection

3. Ears, Nose, Throat:

Clear tympanic membranes, normal nasal mucosa, no oropharyngeal lesions

4. Cardiovascular:

Regular rate and rhythm, no murmurs or gallops, no peripheral edema

5. Respiratory:

Lungs clear bilaterally, no wheezing, no rales (Sabo et al., 2021)

6. Gastrointestinal:

Soft, mild tenderness in lower abdomen, no rebound or guarding, bowel sounds normal

7. Genitourinary:

No CVA tenderness

8. Musculoskeletal:

No joint swelling or tenderness

9. Integumentary/Lymphatic:

No rashes, normal skin turgor

10. Neurologic:

· CN II-XII intact, normal gait

11. Psychiatric:

· Normal affect, no signs of distress

12. Hematologic/Immunologic:

· No lymphadenopathy or signs of anemia

ASSESSMENT (A):

1. Abdominal pain, likely gastrointestinal in origin (possible gastritis or IBS)

2. Rule out gynecological causes (ovarian cyst, endometriosis)

3. No signs of acute infection or obstruction

PLAN (P):

1. Labs:

CBC, CMP, UA

H. pylori test

2. Imaging:

Abdominal ultrasound if symptoms persist

3. Medications:

Proton pump inhibitor (omeprazole) for possible gastritis

Antispasmodic (dicyclomine) for abdominal cramps PRN

4. Lifestyle Recommendations:

Avoid fatty, spicy foods

Increase fiber intake

Hydration and regular meals

Follow-up:

· Re-evaluate in 2 weeks or sooner if symptoms worsen

· Monitor symptom progression and response to treatment

· Schedule additional follow-ups if necessary to adjust treatment plan (Gluppe et al., 2021)

· Consider dietary consultation if lifestyle changes do not improve symptoms

Referral:

· Consider gynecological consultation if no improvement, especially if symptoms suggest endometriosis or ovarian pathology

· Consider gastroenterology referral if symptoms persist despite treatment for possible IBS or gastritis

· Referral to a nutritionist for dietary assessment and improvement

· Psychological evaluation if stress is suspected as a contributing factor

References

Fanslow, J., Wise, M. R., & Marriott, J.(2019). Intimate partner violence and women’s reproductive healthLinks to an external site.. Obstetrics, Gynaecology & Reproductive Medicine, 29(12), 342–350. https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1016/j.ogrm.2019.09.003

Fowler, G. C. (2019). Pfenninger and Fowler’s Procedures for Primary Care (4th ed.). Elsevier. Section 10, “Obstetrics”

Gluppe, S., Engh, M. E., & Kari, B. (2021). Women with diastasis recti abdominis might have weaker abdominal muscles and more abdominal pain, but no higher prevalence of pelvic floor disorders, low back and pelvic girdle pain than women without diastasis recti abdominis.  Physiotherapy,  111, 57-65. https://doi.org/10.1016/j.physio.2021.01.008

Lakhoo, K., Almario, C. V., Khalil, C., & Spiegel, B. M. (2021). Prevalence and characteristics of abdominal pain in the United States.  Clinical Gastroenterology and Hepatology,  19(9), 1864-1872. https://doi.org/10.1016/j.cgh.2020.06.065

Lockwood, C. J. (2019). Key points for today’s ‘well-woman’ exam: A guide for ob/gynsLinks to an external site.. Contemporary OB/GYN, 64(1), 2329. https://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=134229869&site=ehost-live&scope=site&authtype=shib&custid=s6527200

Sabo, C. M., Grad, S., & Dumitrascu, D. L. (2021). Chronic abdominal pain in general practice.  Digestive Diseases,  39(6), 606-614. https://doi.org/10.1159/000515433