SOAP NOTE

SOAP NOTE

Name: R. A Date: 11/19/2018 Time: 14 00 PM
  Age: 30 y/o Sex: Female
SUBJECTIVE
 

CC: “I had been pelvic pain irradiated to the back with my prolong menstrual period.”

 

 

HPI: Patient is a 30-years-old female presents to the office with pelvic pain irradiated to the back, irritability with her prolonged menstrual period.

Medications: No.
PMH: Denies

Allergies: Denies any allergies to food or medication

Medication Intolerances: Denies.

Major traumas: Denies any trauma

Hospitalizations: Denies hospitalizations

Surgeries: Appendicectomy 2014.

 

Family History

Mother: Alive, Diabetes type II.

Father: Alive, High cholesterol, CAD.

Sibling: 1 Sister, Healthy.

 

Children: 1 Healthy.

 

 

Social History:

Home type: Apartment.

Marital status: Married.

Religion: Catholic.

Tattoos: no

Alcohol: wine 1-2 cup only weekends.

Drugs: Denies any Drugs consumption.

Smoker: Non-smoker

Exercise: 30-45 minutes of walk 3 times a week

Travel: Denies.

Blood Transfusion: Denies

OBSTETRIC/GYNECOLOGICAL HISTORY: married, sexually active, Heterosexual, denies STI’s, Menarche: at age of 11. LMP: 11/24/2018. 28 for 5 days, regular cycle, G1T1P1A0L1. Birth Control: Yes/ IUD. One partner

ROS
General

Denies any weight change in the last past 6 months denies weakness, fatigue report monthly. No distress noted at this moment, responding question in an appropriated mood. No exercise intolerance.

Cardiovascular

Patient denies chest pain and palpitation. No edema noticed no syncope, no orthopnea.

Skin

Warm and dry, skin is appropriated color for ethnicity.

Respiratory

Patient denies cough, dyspnea, wheezing or hemoptysis, no acute distress at this moment.

Eyes

Denies changes in vision, no blurred vision, no diplopia, no tearing, no scotomata, and no pain.

Gastrointestinal

No nauseas, no emesis, no dysphagia, no bowel habit changes, no melena, no constipation.

Ears

Denies ear pain, hearing loss, ringing in ears, discharge, pearly grey membranes.

Genitourinary/Gynecological

Report dysuria, frequency or urgency. Denies blood in urine. No urinary urgency, no change in nature of urine. Heavy irregular vaginal bleed.

OBSTETRIC/GYNECOLOGICAL HISTORY: married, Sexually active, Heterosexual, denies STI’s, Menarche: at age of 11. LMP: 11/24/2018. 28 for 5 days, regular cycle, G1T1P1A0L1. Birth Control: Yes/ IUD. One partner.

Nose/Mouth/Throat

Denies difficulty in smelling, sinus problems, nose bleeds or discharge. Denies dysphagia, hoarseness, or throat pain.

Musculoskeletal

Denies cramps, joint stiffness, arthritis or gout, limitation of movement, history of musculoskeletal or disk diseases; denies any muscle or joint pain.

Breast

Denied nipple discharge, breast pain or change in the breast skin.

Neurological

Denies history of headaches, syncope, seizures, stroke, memory disorder or mood change. No weakness, paralysis, numbness/tingling, tremors or tics, involuntary movements, or coordination problems. No mental disorders or hallucinations.

Heme/Lymph/Endo

Denies easy bruising or bleeding. No history of anemia, blood transfusions or reactions. Denies exposure to toxic agents or radiation. / Denies heat or cold intolerance, excessive sweating, polydipsia, polyphagia, or polyuria. No history of diabetes, thyroid disease, or hormone replacement.

Psychiatric

Denies depression, memory changes. Denies suicides attempts or thoughts. No history of mental illness.

 

OBJECTIVE
Weight:  142 lbs   

BMI: 23.6

Temp: 98.9 F BP: 110/77 mm/Hg

Pain: 0/10 on scale of pain

Height: 5’5’’ Pulse: 70 bpm RR: 20 bpm

O2 Saturation: 99 % at Room air

General Appearance

Patient is a 30 y/o WHF, appearing of staged age; Alert and oriented; answers questions appropriately. No acute distress at this time. AAOX4, PERRLA; answers questions appropriately. Pain level: 0/10 on scale of pain at this time.

Skin

General appearance is normal. Normal temperature, Hydrated, no rashes or lesions described. Intact, warm, moist, good turgor. Screening for skin cancer performed no precancerous skin lesion.

HEENT

Head normocephalic, atraumatic and without lesions; hair evenly distributed. Throat: Pharynx mildly erythematous, no exudates. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa edematous, clear rhinorrhea, moderate airway obstruction. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist.

Cardiovascular

No murmur, no rubs or gallop upon auscultation.

Capillary refill 2 seconds. Regular rhythm and rate with S1, S2 normal, no S3 or S4

No edema.

Respiratory

Symmetric chest wall. Lungs: bilateral mildly, lungs clear upon auscultation, no rales, and no wheezes. Breath sounds equal, no rubs. No respiratory distress noted at this time.

 

Gastrointestinal

Abdomen Soft, non-tender, BS normal in all 4 quadrants. No hepatosplenomegaly, mass, or herniation

Breast

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. No axillary nodes.

Genitourinary

The bladder is non-distended; no CVA tenderness.

Genitalia:

Normally developed female genitalia. Vaginal irritation, itching present. No perineal or perianal abnormalities are seen. No urethral discharges.

Speculum examination: A small speculum was inserted gently; Scan vaginal walls bleeding, no cervix discharge, erythema, punctate hemorrhages (strawberry-patch cervix), or friability. Noted small polyp through the cervical canal. Bimanual examination: Enlarged, mobile, irregular uterus contour that is palpable, painful and tenderness.

 

Musculoskeletal

Steady gait, no limping or musculoskeletal deformities, or muscular atrophy. Thoracic and lumbar spine, normal. Full ROM in all 4 extremities, no joint stiffness.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; normal gait.

Reflexes 2+ bilaterally throughout.

CN II-XII intact.

Psychiatric

Good judgment. Alert and oriented. Dressed in clean skirt and blouse. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab /Tests/Screening/Intervention/Assessment:

Laboratory /Diagnostic Test Ordered:

 

CBC, BMP, PT/INR, PTT, Vaginal culture.

Tranvaginal Pelvic Ultrasound: The uterus meansures 8.8 x 7.2 x 7.3 cm apears normal in echogenesis, There is a 1.3 x 1.1 x 0,8 cm intramural fibroid in the posterior uterine body, There is a 1.1 x 0.5 x 0.5 cm separated cyst in the cervix, the endometrial echocomplex mensures 1.7 cm and demostrated increaded echogenicity. There is 4.2 x 2.2 x 1.6 cm hyperchoic lesion in the endometrial cavity, suggestive of a polyp.

The rigth and left ovarys mansures are normal, and appears in normal echoggenicicy and echotenture.

Special Tests:  Not performed.
 Diagnosis
Uterine fibroids due clinical presentation and Physical exam and Transvaginal Pelvic Ultrasound.

Uterine fibroids (ICD 10: D25.9)

Uterine fibroids are benign uterine tumors of smooth muscle origin. Fibroids frequently cause abnormal uterine bleeding, pelvic pain and pressure, urinary and intestinal symptoms, and pregnancy complications. (Merck Sharp & Dohme Corp 2017)

 

Differential Diagnostic:

1. Uterine rupture is spontaneous tearing of the uterus that may result in the fetus being expelled into the peritoneal cavity. (Merck Sharp & Dohme Corp 2017)

2. Uterine prolapse is descent of the uterus toward or past the introitus. Vaginal prolapse is descent of the vagina or vaginal cuff after hysterectomy. Symptoms include vaginal pressure and fullness. (Merck Sharp & Dohme Corp 2017)

3. Uterine sarcomas are a group of disparate, highly malignant cancers developing from the uterine corpus. Common manifestations include abnormal uterine bleeding and pelvic pain or mass. (Merck Sharp & Dohme Corp 2017)

 

Plan/Therapeutics & Education:
 

Medication:

Pharmacologic treatment: 

 

1. Exogenous progestins: Medroxyprogesterone acetate 5 to 10 mg P/O once/day or megestrol acetate 40 mg P/O once/day taken 10 to 14 days.

3. Antiprogestins: mifepristone, the dosage is 5 to 50 mg once/day for 3 to 6 mo.

4. Tylenol 500 mg P/O q/6-8 hrs as needed for pain.

 

Non-medication treatments and education

Patient will be instructed on:

Importance to maintain Hand Hygiene, General Hygiene. Diet habits and life style modification Healthy diet, Normal calorie diet or fat, increased fiber and vegetables in diet. Increase physical activity.

Cervical cancer screening should begin approximately 3 years after a woman begins having vaginal inter- course, but no later than 21 years of age. Screening should be done every year with conventional Pap tests or every 2 years using liquid-based Pap tests.

 

Follow-ups/Referrals:

* Patient need to return to clinic if there is no improvement after 48 hours of treatment, or sooner if their condition is worsening.

* Follow Dr. orders and in case of emergency please call 911 or come to nearest ER.

* Follow up in two weeks to evaluated patient and laboratory testing results.

* Referrals to Gynecologist.

 

 Evaluation of patient encounter:

Interview process went well, practitioner elaborated the plan of care with patient, and education about Uterine fibroids was provided and patient verbalized understanding.

 

 

Uterine fibroids are noncancerous growths of the uterus that often appear during childbearing years. Also called leiomyomas (lie-o-my-O-muhs) or myomas, uterine fibroids aren’t associated with an increased risk of uterine cancer and almost never develop into cancer. Fibroids are generally classified by their location. Intramural fibroids grow within the muscular uterine wall. Submucosal fibroids bulge into the uterine cavity. Subserosal fibroids project to the outside of the uterus. May discover fibroids incidentally during a pelvic exam or prenatal ultrasound.

Many women who have fibroids don’t have any symptoms. In those that do, symptoms can be influenced by the location, size and number of fibroids. In women who have symptoms, the most common symptoms of uterine fibroids include:

• Heavy menstrual bleeding

• Menstrual periods lasting more than a week

• Pelvic pressure or pain

• Frequent urination

• Difficulty emptying the bladder

• Constipation

• Backache or leg pains

Rarely, a fibroid can cause acute pain when it outgrows its blood supply, and begins to die.

Research and clinical experience point to these factors as causes:

• Genetic changes. Many fibroids contain changes in genes that differ from those in normal uterine muscle cells.

• Hormones. Estrogen and progesterone, two hormones that stimulate development of the uterine lining during each menstrual cycle in preparation for pregnancy, appear to promote the growth of fibroids. Fibroids contain more estrogen and progesterone receptors than normal uterine muscle cells do. Fibroids tend to shrink after menopause due to a decrease in hormone production.

• Other growth factors. Substances that help the body maintain tissues, such as insulin-like growth factor, may affect fibroid growth.

• Other medications. Your doctor might recommend other medications. For example, oral contraceptives or progestins can help control menstrual bleeding, but they don’t reduce fibroid size.

Prevention:

By making healthy lifestyle choices, such as maintaining a normal weight and eating fruits and vegetables, you may be able to decrease your fibroid risk.

 

 

References:

 

Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 6th ed. Philadelphia, Pa: Elsevier; 2006.

Merck Sharp & Dohme Corp., Inc., Kenilworth, NJ, USA (2017), Retrieved from http://www.merck.com/

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