Soap note cases for Obstetrics clinical hours PDF

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Examples on how to approach advanced soap notes for obstetrics and gynecology patients. Detailed therapeutics and education for patients...

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OB CASES 30-40 #31 & #32) Maggie A 19-year-old G1 now P1 African-American, two-day post op from a c-section is evaluated for a fever of 101F. She denies nausea or vomiting, but has noticed increased lower abdominal pain since last evening. Her pregnancy was uneventful and she presented to the hospital at 38 6/7 days with rupture of membranes. 12 hours later, she is given Pitocin to induce labor. At the time of birth, she was given Keflex 1 gm for intrapartum prophylaxis. Past Medical History: Med: neg; Surgeries: none; No known drug allergies; Medications: Prenatal vitamins, Iron, Folate. Lab: WBC: 16.9 w/ 70% PMNs Hematocrit: 34 vol. % UA: negative

Initial Visit A: 1. postpartum encounter 2. postpartum endometritis P: 1. Continue taking prenatal vitamin supplements. Educated regarding safety precautions in the house with a newborn, advised not to sleep with baby in bed, avoid newborn exposure to secondhand smoke, and importance of strong support system. Monitor for s/s of mastitis, including redness, pain, or fever. Utilize breast milk or OTC emollient around nipples to prevent cracking. Additional tips include breast massage before latching, alternating breasts, and using correct infant position. Discuss any new medications with OBGYN before using to determine if the medication passes through breast milk. Discussed negative UA and normal Hct lab results which r/o UTI and anemia. 2. Informed pt WBC 16.9 w/ 70% PMNs. Pt symptoms (fever, elevated WBC, and lower abdominal pain) and recent C/S indicate endometritis. Prescribe Clindamycin 600 mg orally every 6 hours plus gentamicin 4.5 mg/kg intramuscularly every 24 hours.Continue to monitor site for s/s of infection and seek immediate medical care if symptoms persist despite antibiotics. RTC in 1 week. Follow up A: 1. Persistent postpartum fever P: 1. Informed patient she requires closer evaluation and testing. Collect UA (-), send patient to nearest ER for transvaginal/pelvic US to look for pelvic abscesses, infected hematoma, or retained products on conception. Discontinue current oral antibiotics and patient will receive IV antibiotics at hospital. RTC 1 week after discharge from hospital.

#33 & #34) Katrina Your patient is a 28-year-old G3P2Ab1 African American who reports that besides being overwhelmed by having a newborn baby, her 2 ½-year-old daughter recently experienced a severe illness. Since that time, she intermittently has thoughts about hurting herself and her children. Her mother is aware of her concerns and is currently caring for the children. During her visit, she describes feeling depressed, sleep deprived, guilty and hopeless. She also states that she has had crying spells and a decreased appetite for the last two months. She can go “a day or two” without being hungry or eating, and she reports feeling like her children “would be better off without me or if they weren’t here.” She has made no plans to act on these feelings, although she notes that these feelings have increased in frequency over the past two months. She states that sometimes when she hears the newborn cry, she thinks she hears a voice in her head telling her to “just shake him until he stops crying.” When she has these kinds of thoughts, she says, she calls her mother or husband or reads the Bible until these thoughts and feelings subside. She worries, however, that one day she will not be placated by these means alone. She admits that occasionally she acts on impulse. She notes that her sister has depression and is treated with fluoxetine. She is a stay-at-home mom who has been married five years. Her pregnancy was uncomplicated and she had a normal vaginal delivery at term. She initially tried to breast feed, but stopped after 3 days due to “sore nipples.”

Initial Visit A: 1. severe postpartum major depression 2. breastfeeding difficulty P: 1. Edinburgh Postnatal Depression Scale with a score of 21 and PHQ-9 score of 19, patient is severely depressed. Educated patient on her signs and symptoms of depression and how it develops during postpartum. Discussed patient is at a high risk of harm to herself and her baby due to depression scale testing. Thus, patient needs to go to the nearest hospital for immediate psychiatric evaluation and treatment. Utilized therapeutic communication and discuss the importance of expressing her feelings. Informed patient she will likely need to be started on antidepressant medication and need routine follow up with a psychiatrist. Recommend utilizing family members help w/ newborn baby and build a strong support system. 2) Educated regarding the importance of breastfeeding and that she can still breastfeed while taking antidepressant medications. Referred patient to lactation consultant. Educated regarding safety precautions in the house with a newborn, advised not to sleep with baby in bed, avoid newborn exposure to secondhand smoke, and importance of strong support system. Monitor for s/s of mastitis, including redness, pain, or fever. Utilize breast milk or OTC emollient around nipples to prevent cracking. Additional tips include breast massage before latching, alternating breasts, and using correct infant position. Discuss any new medications with OBGYN before using to determine if the medication passes through breast milk.

Follow up A: 1. Postpartum depression 2. Postpartum encounter P: 1. Edinburgh Postnatal Depression Scale score is now a 13 and a PHQ-9 score of 12. Continue sertraline 50mg PO daily and routine follow up with psychiatrist and discuss any new medications you are considering taking. Discussed the signs and symptoms of depression and to seek immediate medical care if y o ud e v e l opSI , a n h e d o n i a , t h o ug h t so fha r mi n gs e l fo rot h e r s , o r i n s o mn i a .(2) Continue to take prenatal vitamin supplement. Educated regarding safety precautions in the house with a newborn, advised not to sleep with baby in bed, avoid newborn exposure to secondhand smoke, and importance of strong support system. Monitor for s/s of mastitis, including redness, pain, or fever. Utilize breast milk or OTC emollient around nipples to prevent cracking. Additional tips include breast massage before latching, alternating breasts, and using correct infant position. Discuss any new medications with OBGYN before using to determine if the medication passes through breast milk. RTC in 1 month.

#35 & #36) Melanie A 35-year-old, G1P0, woman presents to your office for a routine prenatal exam. She is 5 days past her due date that was determined by her last menstrual period and a second trimester ultrasound. While reviewing her chart, you note that she has gained 32 pounds during this uncomplicated pregnancy. Today’s exam reveals a weight gain of 1/2 pound since last week’s visit. Her BP is 110/65. She has no glycosuria or proteinuria. The fundal height measures 38 cm and fetal heart tones are auscultated at 120 bpm in the left lower quadrant. The fetus has cephalic presentation and an estimated weight of 8 lbs. Once you walk into the room, the patient expresses her disappointment that she has not had the baby yet. She assumed that she will be having the baby on her due date. She asks you about potential harm to her and the baby from going past her due date, and she would like to know her options.

Initial Visit A: 1. 40 week’s gestation P: 1. Continue taking prenatal vitamins and folic acid. Educated patient regarding diet, active labor symptoms, and OTC medications. Discussed safety precautions, exercise, and travel restrictions. Educated regarding the benefits of breastfeeding and birth control options after delivery. Informed Melanie she and her baby are in stable condition based on fundal height measurement and fetal heart tones. Nonstress test shows normal amniotic fluid surrounding the baby in the uterus. The baby is only considered overdue if gestation lasts longer than 42 weeks. For now, we will monitor the baby until the patient shows active signs of labor. Discussed with patient possible complications of post-term deliveries including breathing problems, placenta problems, lack of adequate amniotic fluid. This will impact the flow of nutrients and oxygen delivered to the baby. We will consider inducing labor if the patient goes past 41 weeks by scheduling an induction of labor. If the trial of labor is not effective, then a C/S may be indicated. RTC in 2 days for another fetal assessment via nonstress test and amniotic fluid volume.

Follow up A: 1. Postpartum follow up 2. Contraception counseling 3. History of post-term pregnancy P: 1. Continue prenatal vitamin supplement, UA (-) to rule out UTI, and hemoglobin (12.7) to rule out anemia. (2) Discuss OCPs, patch, vaginal ring, cervical cap as other options for contraception. Utilize condoms as a source of STD infection prevention, emergency contraception pills available (3) Discuss the risks of another late or postterm pregnancy due to her history. Routine ultrasound examination in future pregnancies can reduce risk for postterm pregnancy. Educated regarding safety precautions in the house with a newborn, advised not to sleep with baby in bed, avoid newborn exposure to secondhand smoke, and importance of strong support system. Monitor for s/s of mastitis, including redness, pain, or fever. Utilize breast milk or OTC emollient around nipples to prevent cracking. Additional tips include breast massage before latching, alternating

breasts, and using correct infant position. Discuss any new medications with OBGYN before using to determine if the medication passes through breast milk. 2. Discussed family planning goals and contraceptive options including risks and benefits of each method. Patients chose Nexplanon, scheduled for insertion within 1 to 5 days of her menses. Side effects and adverse reactions including weight gain, stroke, blood clots, headaches, and emotional lability. Utilize condoms for pregnancy prevention and RTC for Nexplanon insertion.

#37 & #38) Cherie Cherie is a 26-year-old G2PO female who presents to your office for her first prenatal visit. She states that the pregnancy has been uncomplicated, except for one episode of the flu. History reveals that her LMP was 35 weeks ago. She smokes 2 packs of cigarettes a day and has gained 8 lbs. during this pregnancy. Physical Exam: BP 110/70; fundal height is 30 cm. Fetal heart tones are present and normal rate. Obstetrical Ultrasonography Report: Fetal number: Single Position: Cephalic Placenta: Anterior, grade II Amniotic fluid volume: Normal Fetal dating: BPD: 82.9 mm = 33.3  3.1 weeks HC: 299.7 mm = 33.2  3.0 weeks AC: 274.0 mm = 31.5  3.0 weeks FL: 58.0 mm = 30.3  3.0 weeks Humerus: 51.2 mm = 29.9  2.8 weeks. Menstrual age = 34.9 weeks However, Composite sonar age = 31.6  2.4 weeks This represents a size/date discrepancy of 3 weeks that needs to be addressed. Initial Visit A: 1. 35 weeks of gestation 2. Smoking during pregnancy 3. Intrauterine growth restriction 4. Low weight gain during pregnancy P: 1. Continue Prenatal Vitamin and Folic Acid. collect UA w/ culture, hCG, perform PAP, order immunization titers, STI panel, Rh and type, CBC, CMP, GBS screening, blood glucose, quadruple screening for trisomy 18 and 21, and AFP. Educated regarding nutrition, exercise, discussing OTC medication with PCP prior to taking, monitor for s/s of UTIs and avoiding cat litter which may cause your baby to acquire an infection called toxoplasmosis. Educated regarding a healthy weight gain of 25-35 pound throughout pregnancy which is approximately 1 pound per week. Educated on the importance of receiving the flu vaccine during pregnancy to provide passive immunity to the fetus and reduce risk of complications throughout her pregnancy. Also recommend earlier prenatal care to reduce the risk of complications during future pregnancies.2. Discussed the importance of smoking cessation as smoking has numerous adverse effects on the mother and fetal development. Complications include spontaneous abortion, preterm delivery, low birth weight, and placental disorders. Provided patient with support groups to assist her with smoking cessation. 3. Educated regarding size and date discrepancy based on ultrasound and LMP results which showed a 3-week difference. In addition, the findings show signs of slow fetal growth which can be attributed to the mother’s low weight gain and smoking throughout her pregnancy. Patient has normal amniotic fluid volume which rules out oligohydramnios and polyhydramnios. Patient will have Serial UA doppler and ultrasounds every 2 weeks will monitor for any abnormalities that may require an early delivery. 4. Discussed the adverse effects of low weight gain during pregnancy including preterm birth and SGA. Order HgbA1c and OGTT. Recommend fruit, vegetables, whole grains, low fat dairy products, and good sources of protein such as meat, eggs, fish. Avoid fish that are high in mercury or uncooked foods. RTC in 1 week

Follow up A: 1. 36 weeks’ gestation 2. Smoking during pregnancy 3. IUG 4. Low weight gain during pregnancy

P: 1. Discussed lab values from initial visit: Blood type: O, Rh: (-), VDRL: (-), Rubella Immunity (+), HepBAg/Ab (+), Urine (-), Urine drug tox (-), RBS: 85, HIV: (-), Chlamydia (-), GC (-), Pap (-), PPD (-). Educated regarding nutrition, exercise, discussing OTC medication with PCP prior to taking, monitor for s/s of UTIs and avoiding cat litter which may cause your baby to acquire an infection called toxoplasmosis. 2. Offer resources to help with smoking cessation and nicotine patch/gum if patient is still unable to quit. 3. Order another NST with assessment of amniotic fluid, UA doppler, and ultrasound to monitor fetal growth or any abnormalities that may require an early delivery. 4. Reinforced education for future pregnancies including smoking cessation, early prenatal care, and healthy weight gain of 25-35 pounds throughout pregnancy. Recommend patient use WIC to help eat healthy meals that will help her gain weight and improve fetal growth. Diet should include fresh fruits, vegetables, whole grains, low fat dairy products, and good sources of protein such as meat, eggs, and fish that are low in mercury. RTC in 1 week.

#39 & #40) Zelda A 37-year-old female and her 37-year-old husband present with the complaint of a possible fertility problem. The couple has been married for 2 years. The patient has a 4- year-old daughter from a previous relationship. The patient used birth control pills until one-and-a- half-years-ago. The couple has been trying to conceive since then and report a high degree of stress related to their lack of success. The patient reports good health and no problems in conceiving her previous pregnancy or in the vaginal delivery of her daughter. She reports that her periods were regular on the birth control pill but have been irregular since she discontinued taking them. She reports having periods every 5-7 weeks. Past history is remarkable only for mild depression. Imipramine 150 mg qhs for the last 8 months is her only medication. She works as a cashier, runs 12-24 miles each week for the last 2 years, and has no history of STDs, abnormal Paps, smoking, alcohol or other drugs. She has had no surgery. The patient’s partner also reports good health and reports no problems with erection, ejaculation or pain with intercourse. He has had no prior urogenital infections or exposure to STDs. He has had unprotected sex prior to his current relationship, but has not knowingly conceived. He has no medical problems or past surgery. He works as a long-distance truck driver and is on the road 2-3 weeks each month. He smokes a pack of cigarettes a day since age 18 and drinks 2-3 cans of beer 3-4 times a week when he’s not driving. He occasionally uses amphetamines to stay awake while driving at night. The couple has vaginal intercourse about 3 times per week when he is at home. The patient is 5’9” and weighs 130 pounds. Examination of Zelda is completely normal.

Initial Visit A: 1. Infertility 2. Mild depression P: 1. Educate regarding risk factors for infertility including high stress levels, excessive caffeine intake, heavy alcohol use, increased maternal and parental age, intense exercise for females, obesity, sexually transmitted infections, and tobacco use. Excessive alcohol use may cause gonadal function abnormalities, impotence, and reduced testosterone production. Educated on a diet including low fat, foods high in antioxidants, and vegetables. Avoid environmental or occupational pollutant, avoid sexually transmitted infections via safe sex practices. Educated husband on not using amphetamines or other recreational drugs as they can negatively impact fertility. Smoking cessation and limiting alcohol intake will help improve fertility. Recommend sexual intercourse approximately 2-4 times a week. Best time is right after her menstrual cycle ends as this will be right before ovulation. Keep diary of menstrual cycles to accurately time when ovulation will occur. Order STI panel, UA w/ culture, FSH, estradiol, and AMH level, semen analysis, transvaginal US. Also, recommend husband see PCP for routine lab work to r/o other health conditions. 2. Patient educated regarding switching to another depression medication as imipramine may have teratogenic effects especially during the 3rd trimester. However, continue a depression medication is important as symptoms may worsen during and after pregnancy if not treated.

Follow up A: 1. Infertility P: 1. Advised patient and husband to continue utilizing natural conception methods to optimize fertility. Can refer to infertility specialist as well if interventions are not effective. Causes of male infertility include endocrine disorders which affect gonadal function, Primary testicular defects in spermatogenesis, sperm transport disorders, and idiopathic male infertility. Treatment options for women include “In vitro fertilization”, weight reduction, metformin for PCOS, and ovulation induction agents. Male infertility options include treating the underlying condition affecting gonadotropin function or assisted reproductive techniques (ART). Referral to ART clinic given to patients. RTC in 1 month to determine effectiveness of interventions....