MFA Case Presentation Study for Week 7 NR602

11 August 2024

M.F.A Case Presentation Study for Week 7 NR602: Primary Care of the Childbearing and Childrearing Family Chamberlain University Fall 2018 Dwayne V. Ford, RN-BSN

WEEK 7: Women’s Health

Week 7 SOAP NOTE

Patient Information:

  • Name: M.F.
  • Age: 86 years old
  • Gender: Female
  • Ethnicity: Caucasian
  • Insurance: Blue Cross

Subjective:

Chief Complaint (CC): M.F. reports, “I had an operation since the last time I was here, and now I am experiencing dizziness and diarrhea. Also, I need you to check where all my insides were pushed back in—everything was falling out of my vagina.”

History of Present Illness (HPI): M.F. is an 86-year-old female who presents for a follow-up appointment accompanied by her daughter. The daughter explains that the patient underwent a surgical procedure to address prolapse, where both her rectum and uterus were protruding through her vagina. Since the surgery, M.F. has experienced episodes of dizziness, persistent diarrhea, and some episodes of delirium. The patient also complains of sinus headaches and nasal congestion, describing herself as feeling ‘stuffy.’ These symptoms have developed postoperatively, and she is concerned about their ongoing impact on her well-being.

Current Medications:

  • Lisinopril 20 mg: For hypertension management.
  • Atorvastatin 40 mg: For cholesterol management.
  • Vitamin D3 2000 IU: For bone health and vitamin D deficiency prevention.
  • Colace 100 mg BID: To prevent constipation, likely related to her recent surgery and current medications.
  • Levothyroxine 88 mcg: For hypothyroidism management.

Allergies: No known drug allergies (NKDA).

Objective:

Vital Signs:

  • Blood Pressure: 130/82 mmHg
  • Heart Rate: 78 bpm
  • Respiratory Rate: 16 breaths per minute
  • Temperature: 98.6°F (oral)
  • SpO2: 97% on room air

Physical Exam:

  • General: The patient appears frail but is alert and oriented to person, place, and time. She exhibits mild distress due to dizziness and gastrointestinal discomfort.
  • HEENT: Mild nasal congestion, sinus tenderness noted upon palpation. No throat erythema or exudate.
  • Cardiovascular: Heart sounds are regular, with no murmurs, gallops, or rubs.
  • Respiratory: Clear to auscultation bilaterally, no wheezing, rales, or rhonchi.
  • Gastrointestinal: Abdomen is soft, non-tender, with normal bowel sounds. The patient reports loose stools without blood or mucus.
  • Genitourinary: External genitalia inspection shows well-healed surgical scars from the recent prolapse repair. No signs of infection or complications are noted. No vaginal discharge.
  • Neurological: The patient shows signs of mild confusion, but no focal neurological deficits are noted. Reflexes are normal.

Assessment:

  1. Postoperative Complications: Likely related to recent rectal and uterine prolapse surgery, contributing to dizziness and diarrhea.
  2. Sinusitis: As evidenced by sinus tenderness and nasal congestion, possibly contributing to the patient’s headaches and ‘stuffy’ feeling.
  3. Delirium: Postoperative in nature, potentially exacerbated by infection, dehydration, or medication effects.
  4. Dehydration: Secondary to diarrhea and insufficient fluid intake, possibly contributing to dizziness.