Walden University History of The Presenting Illness Discussion

Respondtoatleast two of your colleagues’ posts on two different days and explain how you might think differently about the types of tests or treatment options that your colleagues suggested and why. Use your learning resources and/or evidence from the literature to support your position.

Response to the SOAP note below

Patient Information


Initials MJ, Female, African American


CC: Abdominal pain, nausea, missed menstrual period and bloody discharge.

HPI: Ms. MJ is an 18-year-old African American female that is seen in the office today for complaints of lower abdominal pain that started last night, and bloody discharge that started this morning. According to Ms. MJ, she has not had her menstrual period for a month going to 2 months. Ms. MJ went on to say that she took some Tylenol but does not seem to control her pain.

Current Medications: Tylenol 500mg 2-tab po q 8hours as needed for abdominal pain.

Allergies:No known drugs or food allergies

PMHx: No past medical illness. Patient had COVID 19 vaccine this year, had her flu shot as well. All of her childhood vaccinations are updated.

Soc Hx: Patient is not married, nor does she have any children. She is college student. she work at a restaurant and lives with her mother. She loves to listen to much and read books during her leisure time.

Fam Hx: According to the patient, her mother has HTN, and dad has DM.


GENERAL: Patient reported that she is healthy apart from the new change that involves abdominal pain and bleeding. Denies of chills, fever or malaise.

HEENT: Patient denies of any head trauma.

Eyes: denies of any blurred vision, drainage from her eyes or eye redness or pain.

Ears: No c/o earache or drainage from her ears. Patient reported that she hears well.

Nose: Denies of nasal drip, rhinitis, sneezing or nosebleed.

Throat: No c/o swollen lymph nodes, difficulty swallowing.

SKIN: Denies of skin rash or bruising or trauma.

CARDIOVASCULAR: Patient denies of any chest pain or irregular heartbeat or swollen extremities.

RESPIRATORY: Patient denies of cough, congestion, SOB, or any s/s of respiratory discomfort.

GASTROINTESTINAL: C/O lower abdominal pain that started last night. According to the patient it is a sharp / cramping pain that comes and go extend to lower back area but does not seem to be relieved by pain medication. She experiences the pain even when she is calm and not doing anything. C/O nausea feeling as well.

GENITOURINARY: . Denies of dysuria, burning on urination or urinary frequency.

NEUROLOGICAL: Patient denies of any headache, dizziness, or lightheadedness.

MUSCULOSKELETAL: Denies neck stiffness or neck pain. Denies any limitation to her need movement.

HEMATOLOGIC: C/o vaginal bleeding that started this am. No bruising.

LYMPHATICS: No reported enlarge lymph nodes

PSYCHIATRIC: Denies of depression or any psych issues

ENDOCRINOLOGIC: Denies of excessive urination, tiredness or unexplained weight gain or lose.

REPRODUCTIVE:C/o vaginal bleeding that started this morning. Large bright red blood with some clot in it. Did not have a period for a month going to two months. Have not done a pregnancy test. No hx of contraceptive use. Sexually active without use of protection she reported. Denied using any medication to cause the bleeding or visited a gynecology office where a device was inserted in her vaginal area.


Physical exam: Patient is alert and oriented x3. Verbal with clear speech and able to make her needs known. She does not appear weak or toxic. Appears relaxed with no s/s of pain at this time. Vitals b/p 122/60, pulse 89, r 22, temp 98.0. No SOB noted.

Head: Patient head is normocephalic and atraumatic.

Eyes: Patient pupils are equal, reactive to light and accommodation. Sclera remains white.

Ears: ear drum remains intact with no observed drainage.

Throat: Swallow well with no difficulty.

Respiratory:Patient lungs remains clear with no cough, SOB or abnormal breath sound heard upon auscultation.

Cardiac: S1 and S2 heart sound had with no gallop, or any cardiac complications noted. No edema to Lower extremities or any part of the patient body.

NEUROLOGICAL: Patient is alert and oriented x3. No changes in neurological status.

GI: Patient display facial expression of pain when suprapubic area was palpated. Abdomen soft with positive bowel sound on all four quadrants.

REPRODUCTIVE: Cervical/Pelvic examination revealed adnexal mass. Bright red blood with clot from vaginal noted. No vaginal infectious vaginal discharge noted.

Diagnostic Test:

  • Instant pregnancy test
  • Diagnosed pregnancy by measurement of beta-human chorionic gonadotropin (beta-HCG level). This level will help determine the likelihood of intrauterine pregnancy (Alves & Rapp, 2021). For example, when beta-hCG level is more than 1,500-3,000 mIU/ML, intrauterine pregnancy should be evident on transvaginal ultrasound (Alves & Rapp, 2021).
  • Ultrasound should be done to determine the gestational age and location of the pregnancy (Alves & Rapp, 2021). If an intrauterine pregnancy is not seen in ultrasound with beta-hCG above the discriminatory level, either early pregnancy loss or ectopic pregnancy should be suspected.
  • Wet-prep to r/o infection: Increased number of WBC cells in wet-prep might indicate PID (Jennings & Krywko,2022).
  • NAAT testing to r/o STD infections ( R/O infection from PID that can cause damage of the fallopian tubes (Jennings & Krywko,2022).


Differential Diagnoses:

Ectopic Pregnancy: This pregnancy occurs when the fetal tissue implants outside of the uterus or attached to an abnormal or scarred portion of the uterus (Mummert & Gnugnoli, 2021). Symptoms of ectopic pregnancy includes cramping abdominal pain, vaginal bleeding, or more vague complaints such as nausea and vomiting (Mummert & Gnugnoli, 2021). My patient had complaints of missing her period for the past month going to two months with associated abdominal cramping pain, vaginal bleeding, nausea feeling. Gyn examination that includes speculum visualization of the cervix did revealed adnexal mass. According to studies, adnexal mass findings may indicate ectopic pregnancy (Alves & Rapp, 2021). Furthermore, my patient had no prior documentation of intrauterine pregnancy, and according to recent studies, ectopic pregnancy must be considered in all pregnant patients who have no prior documentation of intrauterine pregnancy (Harris & Grossman, 2020). All the above findings made me to believe that Ectopic pregnancy is the most important diagnosis for this patient.

    : Spontaneous Abortion: Is the loss of pregnancy naturally before twenty weeks of gestation (Alves & Rapp, 2021). The symptom of spontaneous abortion is like that of ectopic pregnancy the difference is that in ectopic pregnancy, the fetal tissue implants outside of the uterus plus the presence of adnexal mass during speculum visualization of the cervix. The similarity of the two disease process symptoms that involve vaginal bleeding, abdominal and lower back pain plus ceased menstrual period for up to two months made me to choose spontaneous abortion as a differential diagnosis.

  • Pelvic Inflammatory Disease: Is defined as an inflammation of the upper genital tract due to an infection in women (Jennings & Krywko,2022). The infection affects the uterus, fallopian tubes, and ovaries (Jennings & Krywko,2022). PID are related to STD (Jennings & Krywko,2022). Symptoms of PID includes cervical discharge, cervical motion tenderness, uterine tenderness, adnexal tenderness, increase WBC in wet prep (Jennings & Krywko,2022). PID symptoms are similar to that of Ectopic pregnancy plus the disease process of PID would result in ectopic pregnancy (Jennings & Krywko,2022). So, this led me to select PID as one of my differential diagnoses.



  • ER transfer for gynecology consult ASAP (if ectopic pregnancy is determined use of IM/IV methotrexate or performance of laparoscopic surgery is safe and effective treatment modalities in hemodynamically stable women with non-ruptured ectopic pregnancy (Mummert & Gnugnoli, 2021). Patients with lower hCG require aa single dose of methotrexate protocol, while a patient with higher hCG level will require two- dose regimen.
  • Order (beta-HCG level)
  • Order an Ultrasound
  • CBC ( R/O anemia from blood loss)
  • Monitor vitals q 2hrs
  • Address the patient pain with pain management.
  • Educate the patient that surgical management of her condition will be warranted if findings revealed intraperitoneal bleeding, symptoms suggestive of ongoing ruptured ectopic mass or hemodynamically instability (Mummert & Gnugnoli, 2021).
  • Educate the patient of the risk of surgical procedure that might involve procedure such as salpingectomy which would be base on how compromised the fallopian tube is.
  • Psych referral for counseling. (It has been proven that women who experience pregnancy loss, grieve intensely and are at risk for psychiatric disorder such as depression and anxiety after the event (Wijesooriya, Palihawadana & Rajapaksha).
  • For possible PID the patient will be treated with doxycycline 100mg po Bid for 2 weeks plus ceftriaxone 500mg IM for one dose as per CDC recommendation, in in-patient setting cefotetan, clindamycin or cefoxtin IV therapy plus doxycycline will be given (Jennings & Krywko,2022).
  • Educate the patient on contraceptive use.
  • Educate the patient on safe sex and use of protection

What I Learned from this Experience

This case experience thought me the critical thinking skills that are needed in the field of practice when trying to formulate differential diagnosis or thinking about treatment plan initiation. Connecting the dot as it pertains to the patient age, cease of menstrual period, symptoms presentation that includes abdominal pain and vaginal bleeding plus clinical findings made me to come up with some tangible differential diagnosis in a split of second for this patient. The other experience that I learned include the dual use of the acting drug methotrexate. I have known the drug to be an immunosuppressant drug for years that is use mostly on autoimmune diseases and in patients with CA. In this particular case, I learned that the medication can also be used to terminate pregnancy (Mummert & Gnugnoli, 2021). I have gained extensive knowledge in dealing with woman and gynecological complications based on this case scenario


Alves, C., & Rapp, A., 2021. Spontaneous Abortion. Stat Pearls. Retrieve from https://www.ncbi.nim.nih.gov.

Jennings, L, K., & Krywko, D, M., 2022. Pelvic Inflammatory Disease. A service of the National Library of Medical, National Institutes of Health. Stat Pearls {Internet}, Treasure Island (FL):StatPearls.

Mummert, T., & Gnugnoli, D, M., 2021. Ectopic Pregnancy. A service of the National Library of Medicine, National Institutes of Health. Stat Pearl {Internet}. Treasure Island (FL): StatPearls. https:


Wijeesooriya, L, R, A., Palihawadana, T, S., & Rajapakasha, R, N, G., A Study of Psychological Impact on Women Und

Schuiling, K. D., & Likis, F. E. (2022). Gynecologic health care (4th ed.). Jones and Bartlett Learning.Chapter 23, “Urinary Tract Infections” (pp. 469–478)Chapter 24, “Urinary Incontinence” (pp. 479–492)Chapter 23, “Menstrual-Cycle Pain and Premenstrual Syndrome” (pp. 495–510)Chapter 26, “Normal and Abnormal Uterine Bleeding” (pp. 511–526)Resources for LGBTQ+Aisner, A. J., Zappas, M., & Marks, A. (2020). Primary Care for Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning (LGBTQ) Patients. The Journal for Nurse Practitioners, 16(4), 281–285. https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1016/j.nurpra.2019.12.011Office of Disease Prevention and Health Promotion (ODPHP). (2020, April 18). Lesbian, gay, bisexual, and transgender health. https://www.healthypeople.gov/2020/topics-objectiv… Sadlak, C. A., Boyd, C. J., & Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ)Health Expert Panel (2016). American Academy of Nursing on Policy: Health care services for transgender individuals: Position statement. https://www.nursingoutlook.org/action/showPdf?pii=…Wingo, E., Ingraham, N., & Roberts, S.C. M. (2018). Reproductive Health Care Priorities and Barriers to Effective Care for LGBTQ People Assigned Female at Birth: A Qualitative Study. Women’s Health Issues, 28(4), 350–357. https://go.openathens.net/redirector/waldenu.edu?url=https://doi.org/10.1016/j.whi.2018.03.002FNP Resources American Academy of Nurse Practitioners Certification Board (AANPCB). (2018). Welcome to the American Academy of Nurse Practitioners Certification Board. https://www.aanpcert.org/American Academy of Nurse Practitioners National Certification Board, Inc. (AANPCB). (2018). FNP & AGNP Certification Candidate Handbook. https://www.aanpcert.org/resource/documents/AGNP%2…Clinical Guideline Resources As you review the following resources, you may want to include a topic in the search area to gather detailed information (e.g., breast cancer screening guidelines; CDC for zika in pregnancy, etc.).American Cancer Society, Inc. (ACS). (2020). Information and Resources about Cancer: Breast, Colon, Lung, Prostate, Skin. https://www.cancer.org/American College of Obstetricians and Gynecologists (ACOG). (2020). https://www.acog.org/ American Nurses Association (ANA). (n.d.). Lead the profession to share the future of nursing and health care. https://www.nursingworld.org/ Centers for Disease Control and Prevention. (CDC). (n.d.). CDC in action. https://www.cdc.gov/ HealthyPeople 2030. (2020). Healthy People 2030 Framework. https://www.healthypeople.gov/2020/About-Healthy-P…The American Association of Nurse Practitioners (AANP). (2020). What’s Happening at your association. https://www.aanp.org/ Document: Focused SOAP Note Template (Word document)

ergoing Miscarriage at a Sri Lankan Hospital Setting. Retrieve


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