Week 6 Response 2

SOAP NOTE

Diagnos tic Test Definition & How the Test Works

Best Suited Conditions/ Diagnoses

Special Considerations/ Instructions

Pelvic Ultrasou nd – Abdomi nal

Non-invasive imaging using sound waves over the abdomen to visualize pelvic organs.

Large fibroids, adnexal masses, uterine enlargement

Full bladder required to improve visualization.

Pelvic Ultrasou nd – Transva ginal

Insertion of a probe into the vagina to produce detailed images of uterus, ovaries, and adnexa.

Fibroids, polyps, endometrial thickness, ovarian cysts

Empty bladder preferred; patient may experience mild discomfort during insertion.

Saline Infusion Sonohys terograp hy (SIS)

Saline is infused into the uterine cavity during transvaginal ultrasound to improve visualization of the endometrium.

Endometrial polyps, submucosal fibroids, intrauterine adhesions

Contraindicated in pregnancy or active pelvic infection. Done in proliferative phase for best visualization.

Hysteros copy

Thin, lighted scope inserted through cervix into the uterus to directly visualize the endometrial cavity.

Polyps, submucosal fibroids, abnormal uterine bleeding

May be done in-office or OR setting; pre-procedure NSAIDs may help reduce discomfort.

Hysteros alpingog ram (HSG)

Contrast dye and X-ray used to assess uterine shape and fallopian tube patency.

Infertility evaluation, uterine malformations

Performed during early follicular phase; contraindicated in pregnancy or infection.

Laparos copy

Minimally invasive surgery using a camera inserted into the abdomen to directly visualize pelvic organs.

Endometriosis, chronic pelvic pain, adnexal masses

Requires general anesthesia; informed consent for risks.

Demographic Data 
 35-year-old African American female (HIPAA compliant)

Subjective
 Chief Complaint (CC): Pelvic pain and irregular vaginal bleeding

Endomet rial Biopsy (EMB)

Tissue sample from endometrium obtained using suction catheter to evaluate histopathology.

Abnormal uterine bleeding, endometrial hyperplasia or cancer

Avoid during pregnancy; may cause cramping or spotting; schedule outside of menses.

Colposc opy

Visual inspection of cervix using a colposcope following abnormal Pap or HPV results; acetic acid enhances visualization of abnormal cells.

Cervical dysplasia, follow-up to abnormal Pap/ HPV

Not first-line for pelvic pain; used only if abnormal cervical cytology is found.

Endocer vical Curettag e (ECC)

Scraping of endocervical canal with a curette to obtain tissue for histologic analysis.

Evaluation of cervical dysplasia or cancer

Often done in conjunction with colposcopy; may cause cramping.

Dilation and Curettag e (D&C)

Cervix is dilated and uterine lining is scraped to obtain tissue or stop bleeding.

Heavy bleeding, incomplete miscarriage, diagnosis of endometrial pathology

Requires sedation or anesthesia; informed consent essential; can be diagnostic and therapeutic.

History of Present Illness (HPI):
 35-year-old African American female presents with a 6-month history of intermittent pelvic pain that is now constant and dull. She describes irregular spotting occurring between monthly menses, which are otherwise regular. No associated fever, chills, nausea, weight changes, or bowel or bladder symptoms.

Additional HPI questions to ask:

When did your last period start?

How long is your typical cycle and flow?

Any recent changes in pattern, severity, or associated symptoms?

History of fibroids, endometriosis, or STIs?

Past Medical History (PMH):
 G2P2 via NSVD (ages 10 and 8). No chronic conditions, surgeries, or STIs. No allergies. Medications: Daily multivitamin. Immunizations up to date. Last Pap smear was 2 years ago and normal.

Family History:
 Mother: hypertension. No breast, uterine, or ovarian cancer in family.

Social History:
 Non-smoker. Social alcohol use. Sexually active with one male partner. Works full time. Diet average, exercises occasionally. No IPV. Inconsistent contraceptive use.

Review of Systems (ROS):

• General: No weight change or fatigue • GI: No constipation or bloating • GU: Pelvic pain and irregular bleeding; no dysuria or hematuria • GYN: No vaginal discharge • Breasts: No lumps or nipple changes • Preventive: Pap up to date; HPV vaccinated; no colonoscopy yet

Objective 
 Vital Signs:

Temp 98.6°F,

BP 118/74,

HR 78,

RR 16,

BMI 23.2

Pelvic Exam Findings:

• External genitalia normal • Speculum: Small amount of blood in vault; cervix smooth, no lesions • Bimanual: Uterus enlarged with palpable firm, irregular contour; no cervical motion

tenderness (CMT); no adnexal masses or tenderness

Assessment

Differential Diagnoses:

• Uterine fibroids (leiomyomas) – most likely due to enlarged, irregular uterus and intermenstrual bleeding.

• Endometrial polyp – possible cause of spotting, especially if intracavitary lesion present. • Adenomyosis – less likely, as uterus typically diffusely enlarged and tender, which this

patient lacks.

Presumptive Diagnosis: Uterine fibroids (leiomyomas)

Confirmatory Diagnostic Test(s):

• Transvaginal pelvic ultrasound – First-line to evaluate uterine size, fibroid location, and structure

• Saline infusion sonohysterography – If concern for intracavitary lesion or endometrial pathology

• CBC – To assess for anemia from blood loss

Plan

Diagnostic Plan:

• Transvaginal ultrasound • CBC • Consider referral to GYN depending on findings

Treatment Plan:

• Ibuprofen 600 mg PO q6h PRN for pain (NSAID) • Combined oral contraceptives (COCs) to help regulate menses and reduce bleeding • Ferrous sulfate 325 mg PO daily if anemia confirmed

Education:

• Discussed fibroids: common, benign smooth muscle tumors of the uterus • Reviewed risks and benefits of COCs (e.g., DVT risk, nausea, breast tenderness) • NSAID education: take with food to minimize GI upset • Nutritional support: increase iron-rich foods if anemic • Potential for surgical management if symptoms worsen (e.g., myomectomy or hysterectomy)

Follow-Up Plan:

• Return in 4 weeks to review ultrasound results and labs • Refer to GYN if large fibroids or unresponsive to medical management

Potential Complications if Untreated:

• Progressive anemia • Increased pelvic discomfort • Possible impact on fertility or future pregnancy • Fibroid growth requiring more invasive treatment

National Guidelines Comparison: 
 According to the American College of Obstetricians and Gynecologists (ACOG), transvaginal ultrasound is the first-line diagnostic tool for uterine fibroids. Initial management for symptomatic fibroids can include NSAIDs and hormonal therapy. Surgical options are reserved for refractory cases or patients desiring definitive treatment.