Soap note for the patient

Subjective

CC: Gynecological that includes fullness in the vagina, which is a suspected case of pelvic organ prolapse.

HPI: The patient shows signs of gynecologic abnormalities. The patient complains of fullness in the vagina when she goes for her annual exam. She notes that the symptoms are more when she stands for a long time. She notes that the feeling has been bothering her to the point that her day to day activities are affected.  She also denies any signs of vaginal bleeding.  However, she does not disclose the timeframe for the symptoms meaning that there is a need to carry further assessment to identify the problem that has been presented. Understanding the history of the present illness is important because it assists in the diagnosis as well as the treatment of the disease in question. She notes that the fullness in the vagina is not accompanied by vaginal bleeding. She confirms that she is not having fecal or urinary incontinence.

Pertinent past medical history

• The patient confirms G5P5, which is an indication that she has had five pregnancy and completed the gestation period.
• She also confirms that she was diagnosed with hypertension and chronic bronchitis. However, she notes that all the diseases have been controlled sufficiently and that they do not affect her day to day activities.
• She also notes that she has never undergone surgery for any medical condition. She also does not provide a pertinent medical history of her parents that could have helped in the diagnosis. The physician is, therefore, forced to use the information that the patient has provided and the physical as well as the laboratory examinations to come up with the necessary diagnosis that will give direction on the treatment process.

Pertinent review of the systems

The patient complains of the fullness of the vagina that worsens when she stands up for a long time. She also notes that she feels bothersome that affects her day to day activities. She does not feel any urinary or fecal incontinence. She does not experience vaginal bleeding. The appearance of the external genitalia is normal. The patient presents relaxation of the posterior and anterior vaginal wall, one centimeter beyond the vaginal opening when the doctor asks her to Valsalva. She also presents descent of the cervix to the same extent as the Valsalva. She has a normal-sized uterus; her ovaries are not palpable, she does not show any signs of rectal masses, and she has a slightly decreased sphincter tone.

Social history

Gladys carries out her day to day activities though she does not reveal the kind of activities that she engages herself in on a day to day basis. She has given birth five times, but more information on her Gravidity and parity is not provided, making it hard to comment on it or use it in the current diagnosis. She sometimes stands for long hours, something that aggravates her symptoms.

Current medications

She has noted that she is undergoing treatment for hypertension and chronic bronchitis, but the medication that she is using has not been disclosed. It is necessary to find out the drugs that the patient has used in the past to aid in the treatment process.

Objective

Vital signs: N/A

Assessment of the patient’s problems (diagnosis)

The process of diagnosis involved physical examination that provided clues on what the patient is suffering from and gives some guidance on the kinds of tests that should be carried out in the laboratory. The results of the physical exam and the lab tests have been shown below. The lab tests then confirm the disease that the patient is suffering from, thus allowing for treatment to commence.

Physical exam:

• A pelvic exam that reveals that the appearance of the external genitalia is normal
• The exam also shows that the vagina and the cervix do not have lesions.
• The patient presents relaxation of the posterior and anterior vaginal wall, one centimeter beyond the vaginal opening when the doctor asks her to Valsalva.
• She also presents descent of the cervix to the same extent as the Valsalva.
• She has a normal-sized uterus, her ovaries are not palpable, she does not show any signs of rectal masses, and she has a slightly decreased sphincter tone.

All pertinent labs, X-rays, etc. completed at the visit

The first diagnostic test that the patient went through was physical, as shown above. The test was aimed at assessing the function of the pelvic floor muscles and the function of the bladder. Bladder function test involved an assessment of whether the bladder empties and whether the bladder leaks, which helped in the determination of the treatment strategy that could be used in the management of the condition. The strength of the pelvic floor muscles and the sphincter muscles was assessed during the diagnosis process. The test assessed the strengths of the muscles and ligaments that support the rectum, uterus, bladder, urethra, as well as the vaginal walls (Rogers et al., 2013).

In the lab, the pelvis was observed with the use of ultrasound technology to provide the correct depiction of the disease that the patient is suffering from. Ultrasound is an imaging method that makes use of high-frequency sound waves to produce images of the bladder, kidneys and the muscles that are located around the vagina and the anus because it is important to be sure of the condition that the patient is suffering from before taking any action (Rogers et al., 2013).

Assessment/problem list

• The fullness of the vagina which is aggravated when the patient stands up for a long time
• Feeling bothersome, which affects her day to day activities.
• The rectal sphincter tone was highly decreased.

Assessment of the patient’s problems (diagnosis)

The current case indicates pelvic organ prolapse, as shown by the tests.  The patient does not present the symptoms of the condition, which include vaginal discharge, increased discharge, and challenges with sexual intercourse, constipation, and recurring bladder infections. However, the patient is at risk of developing the condition because she presents some of the symptoms of the disease, which include protrusion of the vagina and the heavy feeling of the pelvis (Rogers et al., 2013).

The patient has various risk factors that predispose her to the pelvic organ prolapse, which includes:

• The fact that she has been pregnant five times and gave birth successfully means that the patient is at a greater risk of developing the pelvic organ prolapse; hence there is a need to be given the necessary medical attention to arrest the situation or to treat the condition.
• The fact that during the gestation period, she may have given birth to a large baby. However, such information has not been provided by the patient.
• The fact that she has advanced in age and she is getting older also predisposes her to the condition. The risk of pelvic organ prolapse increases as an individual advance in age, meaning that the older a lady becomes, the more she needs to seek medical attention to deal with the situation.

Assessment: a one-sentence description of the problems that the patient is going through

The patient shows the signs of pelvic organ prolapse on the basis of the results of the assessment conducted on the patient.

Plan

Plans for the patient based on the problems identified

The fact that the disease has been identified, the next process involves treatment. The most important support mechanisms for the pelvic organs include the pelvic floor muscle, ligaments, and connective tissues. When the anatomical support fails, then the pelvic organ prolapse occurs. The surgeons, therefore, need to have information on the anatomy of the pelvic floor if they are to manage the anterior, the posterior, and the apical compartment prolapse (Mangir, Roman, Chapple & MacNeil, 2020).

There are several types of pelvic organ prolapse namely Cystocele which is a situation where the bladder prolapses into the vagina and it is the most common condition, urethrocele which is the prolapse of the urethra, rectocele which refers to the prolapse of the rectum, uterine prolapse, vaginal prolapse and enterocele (Rogers et al., 2013).

Diagnostic and treatment plan

Various treatment strategies are available for the patient. The current case disease is rather mild. The patient will be undergoing physical examination and ultrasound to find out If the treatment is successful or not. The treatment strategies that are available include medications that will increase the amount of estrogen, physical therapy, Pessaries, and Surgery. The doctor will discuss with the patient the treatment strategy prior to implementing any of them. The non-surgical treatment strategies will be recommended at this point because the disease is rather mild and manageable. Surgical methods are recommended when the disease is more severe. The patient will be given a schedule for a medical check-up so that her condition can be assessed accordingly. If the patient is not responding to the non-surgical treatments, then the surgical treatment strategies will be recommended. Surgery is therefore recommended as the last resort when all the other treatment methods have failed. There are also cases where the patient could prefer surgery. In such a case, the doctor will give the correct information to the patient to ensure that she is making the right choice (Mangir, Roman, Chapple & MacNeil, 2020).

References

Mangir, N., Roman, S., Chapple, C. R., & MacNeil, S. (2020). Complications related to the use of mesh implants in the surgical treatment of stress urinary incontinence and pelvic organ prolapse: infection or inflammation?. World Journal of Urology, 38(1), 73-80.

Rogers, R. G., Rockwood, T. H., Constantine, M. L., Thakar, R., Kammerer-Doak, D. N., Pauls, R. N., … & Reid, F. (2013). A new measure of sexual function in women with pelvic floor disorders (PFD): the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR). International urogynecology journal, 24(7), 1091-1103