Soap note for OVARIAN CANCER Sample Solution

Soap note for OVARIAN CANCER Sample Solution

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Subjective Data

T.Y is a 77 years old female presenting with vaginal bleeding and abdominal pain. The patient is 27years post-menopause presenting with vaginal bleeding of acute onset, with dark red clots. She states that before vaginal bleeding, she has had abdominal pain in the pelvic region that is of acute onset, dull in nature, does not radiate, aggravated by meals, and relieved by voiding. She states that she experienced bloating, abdominal discomfort, indigestion, reflux, early satiety, weight loss, urine incontinence, and shortness of breath. She has a positive family history of breast cancer, ovarian cancer, and colorectal carcinoma. She is married and lives with her husband. Her menarche was at the age of 17years with irregular menstrual cycles. She has one child born at the age of 45years. She has a bad obstetrics history because she has had three inevitable abortions at 14, 18, and 22weeks gestation. She is 27years post menopause and has been using estrogen hormone replacement therapy to relieve the symptoms associated with menopause like hot flushing.

Objective Data

General: the patient is calm and oriented to time, place, and person. She is weak and emaciated. She is dehydrated and pale. She has no cyanosis, edema, and lymphadenopathy.

Vitals: blood pressure 120/86mmHg, pulse at 101beats per minute, temperature at 36,7 degrees Celcius, respiratory rate at 20 cycles per minute, BMI 32kg/m² and oxygen circulation at 98% room air.

Breast: the breasts have normal skin color and everted nipples without discharge. There is no palpable mass and there is no axilla lymphadenopathy.

Respiratory system: there is a symmetrical chest expansion, resonant percussion note, and clear lung fields with vesicular breath sounds. There are bilateral basal coarse crepitations.

Cardiovascular system: the heart sounds S1 S2 is present without murmurs and gallop. The peripheral pulse is present without bruits.

Abdomen: the abdomen is round and distended to a fundal height of 24 weeks. There is a palpable pelvic mass that is firm and nodular. There are no areas of tenderness. There is a positive shifting dullness and fluid thrill test. The bowel sounds are present and the percussion note is dull. the external genitalia has normal size, shape, and hair distribution. There is no vaginal discharge and signs of inflammation. The cervix is firm, round, and has a tight OS. The ovaries are palpable and there is no cervical motion tenderness.

Diagnostic test: Abdominal pelvic ultrasound and CT scan to determine the source of the mass. Ascitic tap for culture and sensitivity to rule out other causes of ascites. Chest X-ray to rule out lung metastases. Mammogram to rule out breast malignancies.

Assessment

Ovarian cancer C56.9 is a gynecological tumor of the ovaries or metastases from breast cancer. It is mainly an epithelial tumor arising from the fallopian tube. The presenting symptoms are early satiety, abdominal distension, bloating, constipation, vaginal bleeding, fatigue, and pressure on the bladder and rectum (Torre, et al, 2018). The risk factors for ovarian cancer are nulliparity, genetic predisposition, hormone therapy, and endometriosis. Nulliparity is associated with continuous ovulations that cause epithelial trauma from the follicular rapture. Hormonal therapy increases the concentration of progesterone and estrogen thus increasing the incidence of ovarian and breast cancer. Endometriosis increases the risk for ovarian cancer due to exposure to endometrial carcinoma cells. The patient is

Plan

1. Surgery to remove the pelvic mass
2. Paracentesis to drain the excess fluid
3. Chemotherapy

 

References

Torre, L. A., Trabert, B., DeSantis, C. E., Miller, K. D., Samimi, G., Runowicz, C. D., … & Siegel, R. L. (2018). Ovarian cancer statistics, 2018. CA: a cancer journal for clinicians, 68(4), 284-296. https://doi.org/10.3322/caac.21456