soapnote for ob/gyn for uterine bleeding
Homework Answers
Uterine bleeding refers to menstruation or bleeding happens via the birth canal without any actual menstrual cycle. The patient can experience the following and the assessment and planning will be done accordingly
Subjective
- Bleeding in between menstrual cycle
- Bleeding after coitus
- A menstrual cycle lasting more than 5 to 7 days
- A gain in weight
- Pain ,frequency, duration to be mentioned
Objective
- Pale,fatigue or anemic due to loss of blood
- Increased BMI
- Anxiety
- Obese
- breathing difficulties
Assessment
- Physical examination:inspecting for pales ,fatigue due to low iron
- Respiratory pattern:hypoxia decreased SPO2
- Blood investigations:CBC,clotting mechanism ,Sr.iron
- Ultrasound ,MRI,hysteroscopy to ruie our cause
- Biopsy to find our any abnormalities of cancer
Plan
- Administer medication to stop bleeding as per order
- Replace the lost fluid volume to prevent deficit and hypovolemia
- Monitor the vital signs for having the baseline data and plan for care
i need an example of a soapnote for ob/gyn--about uterine bleeding or PID
i need an example of a soapnote for ob/gyn--about uterine bleeding or PID
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