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UNIT 5

DB – SOAP HS 111 – Medical Terminology


Marcia Do Carno

Main Street Medical Center Patient Name: Tana Smith


6000 North Tree Street – Branch, PA Medical Record: 8888888
12345 DOB: 12/10/2000
(555)123-4567 Date of visit: 01/15/2015

S: The patient is a 28 years old female, who has a history of birth control placement in
2012. May of 2014, patient seen by a specialist in female reproductive health, for
dysmenorrhea and irregular bleeding. Upon examination an x-ray of the uterus and
fallopian tube was performed. Patient diagnosed with swelling of the ovary and bleeding
into the fallopian tube with multiple myoma. In June of 2014, patient was schedule for
surgery to unlock a fallopian tube laparoscopically. An exam of the uterus done
vaginally was performed with visualization of two myoma of the uterus on the lower left
wall approximately 3cm and 2.5cm in diameter. At the junction of the fundus and left
salpingo, a 4cm myoma was noted. A surgical removal of the muscle tissue was
performed on the smaller myoma without incident, AD&C was performed. Due to
complications during the procedure, a left salping-oophorectomy was performed. Patient
presents to the ER today with c/o diffuse muscle pain, episodes of syncope, fever, rash
of the face and chest, N and V x 2 days and leukorrhea. Patient states that she
experienced stomach cramps for the last 5 days and diarrhea started today.
O: Vitals: Blood pressure 105/62, temperature 100.7, respiration 22, pulse 96, weight
155, height 5 feet 6 inches.
Skin: abnormal redness of the face, warm, clammy.
Respiratory: Lungs are clear to auscultation and percussion.
Cardio: S1, S2 within m=normal limits, without gallops or murmurs.
Gastro: Abdominopelvic tender to the touch in lower right iliac region, without abnormal
enlargement of an organ mass.
Neuro: Level of consciousness, alert and oriented to person, but confused to time and
place.
Grips: Flexon, extension weak but equal on both sides. PERRL.
Urinary: 100ml cloudy, amber urine. No painful, burning urination, polyuria, or
tenderness with voiding reported. No bladder distention reported.
Lab: Completed blood count, white blood count, blood urea nitrogen, UA, vaginal, troat
and urine cultures.
A: Patient posture is slightly bent, gaint is slow, examination conducted. Patient
disoriented when asked questions, agitated and grimacing upon examination by touch
of the lower right quadrant and posterior left lumbar region. Lower abdominopelvic
region was tender to the touch. No ascites noted, UA performed. Patient placed in
lithotomy position to obtain vaginal cultures. Lab results show elevated white blood
counts – specific to elevated T- cells, anemia, albuminuria and vaginal culture positive
for staphylococci. This raises suspicion of toxic shock syndrome and ARF.
P: Patient admitted and transferred to Intensive Care Unit, started on normal substance
that contains salt and Clindamycin 700mg IV q 8h. Dopamine started IV. Indwelling
Foley catheter inserted via urethra to monitor hourly output. Peri pads used to replace
tampons for the normal flow of blood and tissue from the uterus. VS taken q 2h. Day 2,
patient responding well to in vein infusion of Dopamine and antibiotic therapy. Cultures
obtained. Upon day 3, patient without fever, blood pressure is within normal limits.
Cultures negative for Staph, blood urea nitrogen and liver function tests are within
normal limits.
Discharge orders written: Follow up with OB/GYN in 7days. Until after the follow up
appointment and only if OB/GNY says it is ok, refrain from sexual intercourse, do not
use tampons. Only use peri pads. Take a shower, not a bath, so as to not cause an
infection within the vagina.
Keep vaginal area clean by using sanitary wipes for women after each bathroom break.
Take all medicines as prescribed. No strenuous activity, so as to not cause more
bleeding.