Uterine Fibroids Case Study: SOAP Note and Reflection
This clinical case study examines a 47-year-old obese Hispanic woman (G5P5LC6) presenting with lower abdominal cramping, urinary leakage, fatigue, and cessation of menses for 8–12 months. Using a SOAP-note format, the paper documents the patient's subjective complaints, objective physical examination findings, and diagnostic results, then establishes a primary diagnosis of uterine fibroids alongside differential diagnoses of ovarian cancer, urinary tract infection, and pregnancy. The plan outlines further diagnostic testing and potential pharmacologic and surgical management. A concluding reflection addresses the challenges of assessing an obese patient, the value of early imaging, and the importance of culturally appropriate health promotion for perimenopausal women.
- Patient Presentation and History: Chief complaint, HPI, and full patient history
- Objective Findings and Diagnostic Results: Physical exam, lab results, and key findings
- Assessment and Differential Diagnoses: Primary diagnosis and ranked differentials
- Management Plan: Diagnostic workup and treatment options
- Reflection and Clinical Lessons: Self-assessment and health promotion insights
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What makes this paper effective
- The paper follows the standard SOAP-note clinical format precisely, organizing subjective complaints, objective findings, assessment, and plan in a logical, profession-standard sequence that mirrors real clinical documentation.
- The differential diagnosis section is appropriately prioritized, with brief clinical rationale provided for each alternative, demonstrating critical thinking rather than simple listing.
- The reflection section moves beyond summarizing the case to acknowledge personal clinical decisions the student would alter, showing genuine self-assessment and growth orientation.
Key academic technique demonstrated
The paper demonstrates evidence-based clinical reasoning: each diagnosis and proposed intervention is tied to a peer-reviewed citation, grounding subjective clinical judgment in current literature. This technique — linking each diagnostic or management decision to a supporting source — is a hallmark of graduate-level health professions writing.
Structure breakdown
The paper opens with patient demographics and a full history (subjective), moves to physical examination and lab findings (objective), then presents a prioritized differential diagnosis (assessment), followed by a concrete management plan. The reflection section closes the paper by evaluating clinical decision-making, addressing obesity-related assessment challenges, cultural competence, and health promotion, all supported by citations. This five-part arc is tight and professionally coherent.
Patient Presentation and History
Juanita Morales is a 47-year-old G5P5LC6 Hispanic female who presents with symptoms of lower abdominal cramping, urinary leakage, and cessation of menses for 8–12 months. She is well developed and well nourished but obese (BMI 45.89). She has a negative social history for alcohol, tobacco, and recreational drugs. Her last medical exam was several years ago.
Chief Complaint (CC): Lower abdominal cramping and urinary leakage, along with fatigue, for the past day.
History of Present Illness (HPI): Juanita reports that the abdominal cramping started several hours ago. It is sharp, intermittent, and increasing in frequency and intensity. She tried ibuprofen (Motrin) but it provided no relief. Her menses ceased 8–12 months ago. She also reports constipation, increased gas over the past several months, and possible vaginal spotting several days ago.
Current Medications: None reported.
Allergies: No known drug allergies.
Past Medical History (PMH): No past medical or surgical history reported.
Social History: Negative for alcohol, tobacco, and recreational drugs.
Family History: Not provided.
Surgical History: No history of prior surgical procedures.
Reproductive History: G5P5LC6. Her menopause was described as "easy," with her last menses occurring 8–12 months ago. She was using natural family planning (NFP) for contraception before her periods stopped.
Objective Findings and Diagnostic Results
Physical Exam: Well-developed, well-nourished obese Hispanic female in no apparent distress. There is potential for an abdominal mass, but this is difficult to assess due to her body habitus. The abdomen is otherwise soft and non-tender. Fungal dermatitis is observed under the pannus.
Breasts: Pendulous, with bilateral white/yellow nipple discharge.
Abdomen: Obese; a possible mass is present in the abdomen but is difficult to assess due to body habitus. Otherwise soft and non-tender. Fungal dermatitis is noted under the pannus.
Costovertebral Angle (CVA): No CVA tenderness.
VVBSU: Within normal limits; some watery discharge noted, nitrazine positive. Vaginal mucosa is pink with rugae present. Good pelvic support; no cystocele or rectocele noted.
Cervix: Soft and smooth without cervical motion tenderness (CMT). Os is parous and slightly open.
Uterus: Difficult to assess due to body habitus; however, feels enlarged on bimanual examination.
Adnexa: Not palpated.
Diagnostic Results: Urine dipstick showed specific gravity 1.010, trace blood, negative nitrates, negative leukocytes, negative glucose, and 3+ protein.
Assessment and Differential Diagnoses
Based on the patient's age, clinical presentation, physical examination findings, and initial laboratory results, several possible diagnoses merit consideration.
Primary Diagnosis — Uterine Fibroids: Uterine fibroids are a common cause of an enlarged uterus and can cause abdominal pain, urinary problems, and irregular vaginal bleeding (Ahmad et al., 2023).
Differential Diagnoses:
1. Ovarian Cancer: The patient's abdominal discomfort, urinary symptoms, and fatigue could be symptoms of ovarian cancer (Martin et al., 2020).
2. Urinary Tract Infection (UTI): While her dipstick urine analysis was negative for nitrates and leukocytes, her symptoms of urinary leakage and abdominal discomfort could still suggest a UTI (Vitale & Lockwood, 2020).
3. Pregnancy: Given the history of urinary leakage, abdominal pain, and enlarged uterus, ectopic pregnancy or a normal pregnancy cannot be ruled out despite her age and her report of menopause. This is considered a low probability given her age and history, but it should still be excluded (Dubbewar et al., 2022).
The priority diagnosis at this point is uterine fibroids, given their high prevalence in women around her age and the consistency of her presenting symptoms.
References
Ahmad, A., Kumar, M., Bhoi, N. R., Badruddeen, Akhtar, J., Khan, M. I., ... & Ahmad, M. (2023). Diagnosis and management of uterine fibroids: current trends and future strategies. Journal of Basic and Clinical Physiology and Pharmacology, 34(3), 291–310.
Dubbewar, A., Srivastava, A., Hiremath, R. N., Ghodke, S., Chourey, N., & Sreenivas, A. (2022). A rare case of spontaneous heterotopic pregnancy with intrauterine gestational trophoblastic neoplasia and tubal ectopic pregnancy at a remote secondary care hospital. Journal of Family Medicine and Primary Care, 11(7), 3996–3998.
Martin, M. L., Halling, K., Eek, D., & Reaney, M. (2020). "Lower abdominal pains, as if I was being squeezed… in a clamp": A qualitative analysis of symptoms, patient-perceived side effects and impacts of ovarian cancer. The Patient — Patient-Centered Outcomes Research, 13, 189–200.
Vitale, A. M., & Lockwood, G. M. (2020). Urine microscopy: The burning truth — white blood cells in the urine. Urine Tests: A Case-Based Guide to Clinical Evaluation and Application, 143–166.
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