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MRUSoapNoteRubric2.docx
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SOAPNOTESAMPLEWOMANHEALTH1.docx
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viewdetail-2844-20220111-003.doc
SOAP NOTE: Post-Menopausia bleeding.
STUDENT NAME
MRU
MSN6050 ADVANCE PRACTICE IN PRIMARY CARE- WOMEN’S HEALTH.
SOAP NOTE 1 OB/ POLYCISTIC OVARIAN SYNDROME.
PATIENT INFORMATION
Name: Ms. TM
Age: 57 years old
Race: Hispanic
Gender at birth: Female.
Gender identity: Female.
Source: Patient.
Allergies: Penicillin.
Current medications: Lisinopril 10 mg tab, 1tab daily.
Atorvastatin 20 mg tab, 1 tab daily.
Insurance: PPO.
PMH: Denies.
Surgical History: Appendectomy at 13 y/o.
Immunizations: Influenza. December 2020.
Preventive care: Last PAP smear August 2018. Normal.
Mammogram: Normal. BIRADS 0
Exposure: No knows HIV exposure during the last year. No blood transfusions or received other blood components or tissues.
Environmental exposure was unknown to asbestos, radiations or other chemical substances. No exposure to the sunlight during day activities for long periods of time.
Family History: Father deceased CAD.
Mother alive: 85 y/o, HTN.
Social History: Patient is heterosexual, single, and lives with her husband, roommate, and has a daughter 35 y/o. No domestic violence suspected or negligent behaviors. Client denies using drugs she said that she drinks alcohol only socially. Patient denies smoking tobacco or marihuana.
Nutrition history: She reports a healthy diet, low in sugar and salt.
Chief complaint: “I have my period again”
History of present illness: The patient is a Hispanic female, 57 y/o, G1T1P0A0L1, that
comes to the office staying “I have my period again”. She reports that she has watery, bloody
vaginal discharge for 2 weeks. This never happen before. Her last menstrual period was around 8
years ago. The client denied having had vaginal discharge. She is divorced for three years ago
and she did not have sexual activity since that time. The las pap test was in 2018, and the result
comeback negative. She denies history of sexual assault or trauma, also reports mild
discomfort on pelvic area, no fever or chills. There is not change on her appetite, no weight loss, malaise or weakness.
No previous hospitalizations or invasive procedures in the past twelve months. No history of
mental illness. No physical trauma or falls reported during the last year.
HPI- Women’s Health part:
Menstrual history: Monthly, denies clot or bleeding.
Age of Menarche: 11 yo
Last menstrual period: 2013.
Bleeding pattern. Reports vaginal bleeding during the last 2 weeks.
Associated pain (dysmenorrhea): N/A.
Break through bleeding: N/A.
Length of cycle: N/A.
Average number of days of menses: N/A
Pre-menopause/menopause: Yes. Vasomotor symptoms: Yes.
Hormone replacement therapy: No.
Condom use: No.
Vaginal douches: No.
Level of satisfaction with sexual activity: good
History of sexual assault: no
Contraceptive use: N/A.
Previous method, including complications, reason discontinued: Same method.
Cervical and vaginal cytology: 2013. Normal
Most recent PAP Smear: Normal.
History of abnormal PAP Smear? Denies.
History of sexually transmitted infections: She denies having had any sexually transmitted disease.
Vaginitis: Denies. History of Pelvic inflammatory disease? Denies.
Any difficulty conceiving in the past? Denies.
Sexually active: Yes, she has a fixed partner for the last 35 years.
History of sexual abuse or sexual assault: Denies.
Obstetric history:
G 1
T 1
P 0
A 0
L 1
Describe any maternal, fetal, or neonatal complications? Denies.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Denies fever, chills or malaise. Denies low energy in the past two weeks as identified in the PHQ-9 questionnaire. Denies weight loss, change of appetite.
NEUROLOGIC: Denies headache, changes in LOC, history of tremors or seizures, weakness, numbness, dizziness, headaches. Denies trouble walking, syncope, sleep disorder, memory problems.
PSYCHIATRIC: Mood was euthymic, not feeling restless or anxiety. No feeling hopelessness or depressed. No sleep disturbances, trouble falling or staying asleep. Normal enjoyment of activities. Not easily distracted and no change in thought patterns.
HEENT: Head: Denies head injuries, or change on LOC. Eyes: No irritation, no drainage, no dry eyes, no pain on eyes’ structures or retro-orbital, no vision changes, no diplopia, or blurred vision. Ears: Denies loss of hearing, no ear pain, no drainage, no sensation of ears feeling full, no ear ringing, or ears’ trauma. Nose: Denies nasal congestion, no nasal drainage, no nosebleeds, and normal smell sense. Throat/Mouth: Denies sore throat, no hoarseness, no difficulty swallowing, or postnasal drip. No mouth sore, no thrush, no bleeding gums, no lips sore, no teeth problems.
NECK: Denies neck pain, no masses, no nodules, no history of thyroid abnormality.
RESPIRATORY: Denies chest congestion or wheezing, coughing, shortness of breath.
CHEST/ BREAST: Denies chest abnormalities, no breast lumps, no nodules, no nipple drainage, or nipple retraction.
CARDIOVASCULAR: Denies chest pain, palpitations. No orthopnea, or paroxysmal nocturnal dyspnea. Denies edema, irregular heartbeat, low or high blood pressure, poor circulation, cold extremity, or claudication.
GASTROINTESTINAL: Normal appetite as identified in the PHQ-9 questionnaire. No dysphagia or heartburn. No nausea, vomiting or abdominal pain. No hematochezia. No diarrhea or constipation.
GENITOURINARY: Denies dysuria, frequency, urgency, hesitancy, incontinence, nocturia, or
hematuria. No history of UTI and kidney infections
EXTERNAL GENITALS: The patient reports watery, bloody vaginal discharge for 2 weeks
and mild discomfort over the pelvic area. No history of STD.
MUSCULOSKELETAL: Denies fall, muscle or joint pain. Denies hearing a clicking or snapping sound. Denies numbness, hemiplegia o paresthesia, muscular atrophy or weakness. Denies limited range of mobility, joint pain or limited ROM.
HEMATOLOGIC: Denies easy bruising, loss of hair, heat/cold intolerance, changes in nails, enlarged glands, prolonged bleeding, increased thirst, or hunger.
SKIN: Denies skin rash, no wound, no change on skin color or texture, no change in a mole, no unusual growth, no dry skin, no itching, or jaundice. Hair: Denies hair loss, no hair abnormalities. Nails: Denies nails abnormalities, no discoloration, no clubbing, no cyanosis, or longitudinal ridges.
OBJECTIVE DATA:
VITAL SIGNS: Temperature: 97.9 F0, Pulse: 86 BPM, BP: 123/77., RR: 18 per min.
PO2- 98 % on room air.
Gynecological examination was performed in the office.
GENERAL APPEARANCE: Patient alert and oriented. Speech fluently. Patient does reflex discomfort in her face and posture secondary to the pain on her genitals
NEUROLOGIC: Alert, CNII- XII grossly intact, Oriented to person, place and time. Sensation: Intact to Bilateral upper and lower extremities. Bilateral UE/LE strength 5/5. Romberg is negative and the patient has stable and balance gait. Reflexes 2 + symmetrical with negative Babinski. No asterixis. Proprioception was normal
PSYCHIATRIC: Cooperative but stressed about her genital condition. Patient is euthymic. The affect was normal.
HEENT: HEAD: Normocephalic, atraumatic. Symmetric, nontender. Maxillary sinuses, no tenderness. Scalp pink and dry. EYES: No conjunctival secretion or injection, no icterus, extraocular eye movement intact. No nystagmus noted. Symmetrical pupils, light reactive, Visual acuity 20/20 with the use of reading glasses. EARS: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. NOSE: Nasal mucosa moist without bleeding. Clear nasal discharge. MOUTH AND THROAT: Oral mucosa moist without internal lesions such as canker sores, ulcers or vesicle. Tongue and uvula movement preserved without deviations.
NECK: No pain, no cervical lymphadenopathy, no jugular vein distention the palpation thyroid is mobile when the patient swallows, centrally located without evidence, or increased in size, trachea is midline. No murmur at the level of the carotid arteries. No visible mass and skin with normal coloration. No palpable masses or tenderness, thyroid without nodules, no JVD, no lymph nodes. Pharynx: Moist and pink without tonsillar enlargement. No noted lesions or exudate.
CARDIOVASCULAR: S1S2, regular rate and rhythm, no S3 or S4, no murmurs or gallop noted, PMI at 5th intercostal space, midclavicular line. No pericardial friction rub heard.
All pulses 4+ palpable and equal. No clubbing, cyanosis or edema noted. Bilateral carotid arteries without bruits. Capillary refill test < 2 sec.
RESPIRATORY: Respirations are regular, equal, and unlabored with symmetrical chest expansion. No egophony whispered pectoriloquy, or tactile fremitus, on palpation. Breath sounds presents and clear bilaterally, on auscultation. No wheezing, stridor, crackles, or rhonchi noted. No increased tactile fremitus noted. Lungs resonant.
CHEST: Breast: Normal in size. Symmetric. Two normal nipples without discharge. No skin changes (rashes, lesions, dimpling or retraction). No masses or tenderness.
GASTROINTESTINAL: Inspection: Symmetric, no distended no visible masses. The skin
is normal, appendectomy 4 cm scar located on RLQ. Auscultation: Bowel sound active in all 4
quadrants. No bruits. Palpation: Abdomen soft, mild tenderness on lower abdomen, non
distended, no masses, herniation, guarding, rebound tenderness. No hepatomegaly or
splenomegaly. Percussion: Normal.
GENITOURINARY:
External genitalia: Mons normal hair distribution, no lesions. Labia majora, minora and
clitoris normal. Bartholin’s and Skene’s glands normal. Urethra WNL.
Vagina: Rugate, pink/red, inflamed wall, no discharge, good tone, no cystocele,
rectocele or masses.
Kidneys: Both kidneys have normal size, they are not palpable. Costovertebral angles are
not tender on palpation and percussion. The bladder is not palpable or tender.
Cervix: Small, no lesions, masses, inflammation, bloody discharge, negative for cervical
motion tenderness, no ectropion.
Uterus: Big firm, lateral, hard and not mobile, tender to motion.
Adnexa: Thickness of right parametrium. Ovarium not palpable.
MUSCULOSKELETAL: No evidence of atrophy, tumor. No pain to palpation. Active and passive ROM within normal limits, no stiffness. No peripheral edema. Stable gait.
INTEGUMENTARY: Intact, no cyanosis or jaundice, Nail without alterations: no mycosis, angle 160 degrees (no clubbing). Hair distribution in the preserved leg area, no area of paleness or redness, symmetrical calf diameter.
ASSESSMENT:
Main Diagnosis: Postmenopausal bleeding. ICD 10 N95.0-). Postmenopausal bleeding: refers to any uterine bleeding in a menopausal woman, it occurs on 5% of the postmenopausal population, and between 6-19 % is due to Endometrial cancer. In general, all postmenopausal women with unexpected uterine bleeding, should be evaluated for endometrial carcinoma, which is a lethal disease cause of bleeding, however, the most common cause of bleeding in these women is atrophy of the vaginal mucosa or endometrium; in the early menopausal years, endometrial hyperplasia, polyps, and submucosal fibroids are also common etiologies. (Goodman et al 2021). This patient present to the office after her menopause years ago, with symptoms, signs, and physical examination correlated with Post-menopausal bleeding. We must rule out the Endometrial Carcinoma as a cause of postmenopausal vaginal bleeding, discomfort on lower abdomen.
Also, the positive findings at bimanual vaginal examination of big firm, hard, lateral uterus, not mobile, tender to motion, thickness of right parametrium place that option the first in line.
The Differential diagnosis are with:
Cervical polyps: The cause is unknown, but inflammation play an etiologic role, the
principal symptoms are discharge and abnormal vaginal bleeding, the polyps are visible in the
cervical os on speculum examination. (Papadakis & McPhee, 2017)
Post-coital vaginal laceration: Appears frequently in postmenopausal women with
atrophic vagina due to low levels of estrogens. It is not uncommon to experience some amount
superficial trauma or tears to the vagina especially after a lengthy session of intercourse. It is
usually, painless. However, at times, the trauma to the vagina can be quite extensive, requiring
emergency intervention (Domino, 2017).
Atrophy of the endometrium and vagina: Secondary to the hormonal changes of the
menopause the hypoestrogenism could cause changes included atrophy of the endometrium and
vagina. It produces micro erosions of the epithelium, associated to chronic inflammation, and it
facilitate the bleeding. Then during the examination, you can find a dry vaginal epithelium that it
is smooth and shiny with loss of most rugation. Then, the blood vessels could be visible, and
there is a chance of bleeding. (Goodman et al 2021).
Endometrial Hyperplasia: It is a frequent cause of vaginal bleeding on menopause women.
Despite the expected decrease of the endogenous estrogen production, secondary to ovarian or
adrenal tumors or exogenous estrogen therapy, we can find endometrial hyperplasia, therefore,
patient can present with vaginal bleeding. (Goodman et al 2021).
Differential Diagnosis:
· Endometrial Hyperplasia (ICD 10 N 85.00)
· Atrophy of the endometrium and vagina (ICD 10 N95.2)
· Cervical polyps: (ICD10. N84.1)
Plan:
Lab/Tests: CBC with Diff, CMP, Lipid Panel, SR, UA, Vaginal and cervix culture, Pap
smear test, Abdominal and Transvaginal US.
Pharmacological treatment:
None at this moment
Non-Pharmacological treatment:
None at this moment.
Education: Patient is educated on possible causes of post-menopausal bleeding,
importance of lab/test ordered to set diagnosis, management, when to contact physician. Also,
the client is advised that the bleeding becoming heavy or she feels weakness contact the
physician or go to the near emergency room. The patient is instructed on the importance to
regular screenings. This can help detect conditions before they become more problematic.
Maintain a healthy weight, following a healthy diet and exercising regularly. This alone can
prevent a variety of complications and conditions throughout the entire body.
Follow-ups/Referrals. Return in 3 days after lab/test done to be re-evaluated and referral
SOAP NOTE: VULVOVAGINAL CANDIDIASIS.
4
SOAP NOTE # 2: POST-MENOPAUSAL BLEEDING.
to gynecologist if required.
References
1. Domino, F. J. (2017). The 5- minute clinical consult. (25th ed.). Philadelphia, PA: Wolters
Kluwer.
2. Goodman, A., & Barbieri, R. L. (2021, February 2). Postmenopausal uterine bleeding. Retrieved February 06, 2021, from https://www.uptodate.com/contents/postmenopausal-uterine-bleeding?search=Postmenopausal%20bleeding&source=search_result&selectedTitle=1~79&usage_type=default&display_rank=1
3. Hacker, N. F., Joseph, G. C., & Calvin, H. J. (2016). Hacker & Moore' s Essentials of Obstetrics and Gynecology. (6 ed.). Missouri: Elsevier.
4. Papadakis, M. A., & McPhee, S. J. (2017). Medical diagnosis and treatment (56th ed.). San Francisco, CA: Mc Graw Hill Education.
