| Name:A.R. | S O A P | Time:3.20 p.m. | |
| Date:9/20/2017 | Age:32 y/o | Sex:F | |
| SUBJECTIVE | |||
| CC: “I have right lower abdominal pain.” | |||
| HPI: Mrs. A.R. comes to the office because of having lower abdominal pain since 5 days. This is the first time she has that kind of pain. The pain increases with physical activity and after eating. The characteristics are dull pain 6 to 7 of 10.The pain decreased after taking 500 mg of Tylenol and when she lies down. Last menstrual period was two weeks ago and is regular with moderate amount of blood lasting 4 days. She denies that the pain has any type of radiation, denies fever vaginal discharge or urinary complaints. She passes gasses regularly and has fecal voiding normally. There is also no other discharge or pelvic symptoms in other days. | |||
| Medications: Acetaminophen 500 mg po qd | |||
| PMH Allergies: She does not suffer from any environmental, food, or drugs allergies Medication Intolerances: There is no medical data about medication intolerances. Chronic Illnesses/Major trauma Denied OBGYN HxMenarche 11 year old G 2 P 2 normal delivery LMP (Regular) 2 weeks ago Pap smear 2016 Normal: | |||
| Family History Father is alive. He has hypertension. Negative for heart disease, tuberculosis, other medical illnesses Mother is alive. Negative for cancer, heart disease, hypertension, tuberculosis, other medical illnesses | |||
| Social History The patient is socially active. She is married uses condoms and rhythm works as a clerk does not do exercise. She does not use tobacco or drugs, she drinks once or twice a month socially. She only has sexual activity with her husband. She has good family relations with her children and husband. | |||
| ROS | |||
| General | Cardiovascular | ||
| Patient has lost 10 pounds last 6 months. She denies, fever, and night sweats. | The patient does not have cardiovascular complaints. She denies chest pain. edema, orthopnea, etc. |
| Skin No reports of rash,lesions,delayedhealing,bruising,bleedingorskindiscolorations. The patient denies any changes in moles. | Respiratory There are no signs of problems. The patient deniesshortnessofbreath,cough,congestion,wheezing,hemoptysis,dyspnea.There is also no tuberculosis relate symptoms history. |
| Eyes There are no reported problems with sight. The patient denies blurring, visual changes of anykind.She does not visit ophthalmologists regularly because does not feel the need for it. | Gastrointestinal She has abdominal bloating and sometimes nausea after eating since 4 months ago. The patient denies hepatitis, hemorrhoids, eating disorders, ulcers, blacktarrystools. Stools are regular, last was today, she passes gases |
| Ears The patients hearing is fine. She has never experienced ear pain, hearing loss, ringing in ears, etc. There are no signs of ear traumas. | Genitourinary/Gynecological The patient has increased pelvic pain 5 -6 /10 since 5 days ago. Pain is dull no radiated that improves with acetaminophen 500 mg and worsen after eating There is no unusual vaginal discharge. The patient denies bleeding between menses. |
| Nose/Mouth/Throat The patient does not have any oral cavitys diseases. She denies a sorethroat,discharge,dysphagia,nosebleeds,dentaldisease,hoarseness. | Musculoskeletal The musculoskeletal development is normal. No signs of dystrophy. She denies trauma, backpain, hippain. Denies fracture.The examination does not demonstrate any visible problems in the sphere. |
| Breast There are no signs of breast cancer. The patient denies lumps, bumps or changes.There is no breast cancer history in the family. | Neurological She does not experience spontaneous episodes of weakness, memory loss, mental problems, etc. | ||
| Heme/Lymph/Endo The patient is not a donor. She denies blood transfusion. There is no extreme sweating, alterations in her appetite, etc . | Psychiatric Denies depression, anxiety sleeping disorder, suicidal attempts, etc. | ||
| OBJECTIVE | |||
| Weight:156lbs BMI:27.3. | Temp:96.7tympanic | BP:130/85left armsitting | |
| Height:5’3 | Pulse:98 x min | Resp:18 x min. Oxy Sat 98% | |
| General Appearance Female not in distress cooperative answers willingly and appropriately. | |||
| Skin The patients skin is of normal color. It is warm, clean, without spots or some other problems. | |||
| HEENT The patients head is normocephalic. It is symmetric. There are no lesions. Her hair is distributed in accordance with the sex character. No tenderness. No signs of major traumas. The patients eyes demonstrate no signs of significant health problems. Pupils are equal, round and reactive to light and accommodation. Extraocular movements are intact. The sclera is clear. Ears: Landmarks are visualized. No signs of problems with hearing. Positive light reflex. Nose: No visible problems. Mucosa is fine and pink. There are no deviations. Neck: Pharynx is pink. Oral mucosa is fine. Problems with occlusion that should be corrected Teeth are fine. There are no nodules. Finally, no lymphadenopathy or thyromegaly are discovered. Oral mucosa is moist and pale pink | |||
| Cardiovascular No extra sounds. The rate and rhythm are regular. Capillary refill – 1,9 seconds. There is no edema. | |||
| Respiratory The patients chest wall is symmetric. She demonstrates regular respirations. There are no problems with breathing. | |||
| Gastrointestinal The patients abdomen is flat, soft. Responds to palpation in a normal way. Active in all quadrants. There are no signs of visible health problems. | |||
| Breast | |||
| Breast exam proves the absence of health problems. No signs of breast cancer. No calcifications. The overall state could be described as normal. |
| Genitourinary External exam: Vulvais pink, without any traumas or signs of damage. There is no discharge on the walls. Pelvic examination speculum shows vaginal mucosa pink, no secretions, os closed., bimanual exam shows uterus anteverted no mases mild tender to palpation. Adnexa is palpable. Very tender at right mild tender to the left. No guarding no rebound. Rectal exam demonstrates pain to right adnexa to bimanual palpation, mases or signs of traumas. No bleeding. |
| Musculoskeletal The patient demonstrates no musculoskeletal pain when moves. All gestures are painless. The locomotor apparatus is fine. |
| Neurological The patients speech is clear. She responses to all answers in an appropriate way. Demonstrates an appropriate level of cognitive activity. Reflexes are intact. Balance is stable. No visible neurologic diseases. |
| Psychiatric The patient maintains the eye contact. Speech is clear. Understands all questions. Demonstrates anxiety because of the pain during menses. No visible signs of mental disorders. The family history also does not contain any records of this sort. |
| Lab Tests CA 125 blood test (cancer antigen) – tumor markers are found. Level of CA-125 is high. It indicates the presence of a certain type of cancer (“Cancer antigen 125 (CA-125)”, n.d). Transvaginal ultrasound – a mass (tumor) in the right ovary is found. It is 6 cm complex mass MRI – proves that a pelvic mass is present. Ovarian cancer has not spread to other tissues and organs (“Tests for ovarian cancer,” n.d.). CT – other big tumors were not discovered. |
| Special Tests– Surgery – to remove a tissue sample and abdominal fluid to prove the final diagnosis. |
| ASSESSMENT FINDINGS AND PLAN |
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| The patient suffers from symptoms that could indicate several similar and complex diagnoses. The three main differential diagnoses are a malignant neoplasm of right ovary, benign neoplasm of right ovary, and malignant neoplasm of unspecified ovary. The causes for the appearance of these symptoms are vague. The lifestyle and sexual activity could hardly impact the development of a tumor. The patient uses condoms, and the impact of hormonal pills should also be excluded. The patient is not obese (one of risk factors (Foong & Bolton, 2017)). For this reason, there are both environmental and hereditary factors that triggered the growth of the ovarian tumor (Green, n.d). It is crucial to investigate the patients family health history and examine her mother for cancer markers as she belongs to the risk group. At the moment, the patient suffers from the pain in the lower abdomen. For this reason, the above-mentioned diagnoses could be applied to the case. However, considering her weight loss (one of the main symptoms of cancer) malignant neoplasm of ovary becomes the most obvious diagnosis (Lim & Ledger, 2016). |
| The patient should be tested to prove the final diagnosis (malignant neoplasm of the right ovary). First, a CA125 blood test to discover cancer markers and monitor the level of CA125 is needed. It specifies the type of the tumor (benign or malignant). Furthermore, a transvaginal ultrasound will help to locate the tumor and the ovary affected by the disease. MRI investigation could also be recommended to assure that the pelvic mass is present. Finally, CT will help to exclude the existence of other big tumors in the body. |
Presumptive Diagnosis: Malignant neoplasm of right ovaryPlan:
EducationThe patient should be informed about the great danger that comes from any type of cancer and peculiarities of its treatment. It is essential to demonstrate statistics which shows that patients with early stages have more changes for complete recovery. For this reason, it is crucial to monitor the state of the health. The patient belongs to the risk group, and she should visit her gynecologist regularly to avoid complications and another case of cancer. Furthermore, the patient should be educated about different prophylactic measures to improve the state of the health after the surgery and chemotherapy. The given intervention could be challenging and great attention to the recovery period should be devoted. The high risk for cancer could be considered a hereditary factor. It means that the patient should also explain her children the existing risks and monitor the state of their health. Finally, the list of main risk factors that could precondition the development of cancer should be offered to the patient to minimize their negative impact and avoid disease recurrence in future. Follow-Up
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| Self-Assessment The importance of the case is evidenced by the scale of the problem analyzed in it. Ovarian cancer, as well as other types of cancer, is the great problem the modern healthcare sector faces. Unfortunately, a significant number of cancer cases are complicated by several factors. Very often patients come at late stages when other organs are affected by the tumor. Statistics evidence that individuals who address a physician at the first stages have better chances to recover (Pietrangelo & Cafasso, n.d.). For this reason, the case contributes to the improved comprehending of the issue and of the necessity to create an appropriate treatment plan. It is crucial to determine the type of cancer and chose an efficient treatment. The given investigation provided us with the relevant information about modern approaches to the ovarian tumor and with experience that could be applied to similar issues in terms of a certain medical unit. |
References
Cancer antigen 125 (CA-125). (n.d.). Web.
Foong, K., & Bolton, H. (2017). Obesity and ovarian cancer risk: A systematic review. Post Reproductive Health. Web.
Green, A. (n.d.). Ovarian cancer. Web.
Lim, H., & Ledger, W. (2016). Targeted therapy in ovarian cancer. Women’s Health, 12(3), 363-378. Web.
Nguyen, L., Cardenas-Goicoechea, J., Gordon, P., Curtin, C., Momeni, M., Chuang, L., & Fishman, D. (2013). Biomarkers for early detection of ovarian cancer. Women’s Health, 9(2), 171-187. Web.
Pietrangelo, A., & Cafasso, J. (n.d.). Ovarian cancer: Early symptoms, detection, and treatment. Web.
Tests for ovarian cancer. (n.d.). Web.